Provider Demographics
NPI:1790845493
Name:JOHNSTON, RUSSELL G (MD)
Entity Type:Individual
Prefix:DR
First Name:RUSSELL
Middle Name:G
Last Name:JOHNSTON
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:17390 BERKSHIRE DR
Mailing Address - Street 2:
Mailing Address - City:JEFFERSONTON
Mailing Address - State:VA
Mailing Address - Zip Code:22724-1702
Mailing Address - Country:US
Mailing Address - Phone:540-937-3969
Mailing Address - Fax:
Practice Address - Street 1:PRINCE WILLIAM HOSPITAL
Practice Address - Street 2:8700 SUDLEY ROAD
Practice Address - City:MANASSAS
Practice Address - State:VA
Practice Address - Zip Code:20011-4418
Practice Address - Country:US
Practice Address - Phone:703-379-8000
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2006-12-11
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
VA0101028362174400000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes174400000XOther Service ProvidersSpecialist
Provider Identifiers
StateIdentifier IDID TypeIssuer
VA5707200Medicaid
VA5707200Medicaid