Provider Demographics
NPI:1851413488
Name:JOHNSTON, TRACY MARIE (MD)
Entity Type:Individual
Prefix:DR
First Name:TRACY
Middle Name:MARIE
Last Name:JOHNSTON
Suffix:
Gender:F
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:130 PEYTON ST
Mailing Address - Street 2:
Mailing Address - City:WINCHESTER
Mailing Address - State:VA
Mailing Address - Zip Code:22601-3935
Mailing Address - Country:US
Mailing Address - Phone:540-723-0611
Mailing Address - Fax:540-723-9875
Practice Address - Street 1:130 PEYTON ST
Practice Address - Street 2:
Practice Address - City:WINCHESTER
Practice Address - State:VA
Practice Address - Zip Code:22601-3935
Practice Address - Country:US
Practice Address - Phone:540-723-0611
Practice Address - Fax:540-723-9875
Is Sole Proprietor?:No
Enumeration Date:2007-04-04
Last Update Date:2018-03-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
VA0101242929207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
VA1851413488Medicaid
VA1851413488Medicaid
VAVV4734Medicare PIN