Provider Demographics
NPI:1831288422
Name:JOHNSTON, CHARLES BRADFORD (MD)
Entity Type:Individual
Prefix:
First Name:CHARLES
Middle Name:BRADFORD
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 1:1102 CHICAGO AVE
Mailing Address - Street 2:
Mailing Address - City:OAK PARK
Mailing Address - State:IL
Mailing Address - Zip Code:60302-1804
Mailing Address - Country:US
Mailing Address - Phone:708-948-7772
Mailing Address - Fax:708-948-7773
Practice Address - Street 1:1102 CHICAGO AVE
Practice Address - Street 2:
Practice Address - City:OAK PARK
Practice Address - State:IL
Practice Address - Zip Code:60302-1804
Practice Address - Country:US
Practice Address - Phone:708-948-7772
Practice Address - Fax:708-948-7773
Is Sole Proprietor?:Yes
Enumeration Date:2006-10-12
Last Update Date:2010-12-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL036078749207R00000X, 208000000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207R00000XAllopathic & Osteopathic PhysiciansInternal Medicine
No208000000XAllopathic & Osteopathic PhysiciansPediatrics
Provider Identifiers
StateIdentifier IDID TypeIssuer
ILE40938Medicare UPIN
IL206971Medicare ID - Type Unspecified