Provider Demographics
NPI:1851489223
Name:JOHNSTON, NICOLE BISHOP (MD)
Entity Type:Individual
Prefix:
First Name:NICOLE
Middle Name:BISHOP
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 1:4300 W MAIN ST
Mailing Address - Street 2:SUITE 31
Mailing Address - City:DOTHAN
Mailing Address - State:AL
Mailing Address - Zip Code:36305-1054
Mailing Address - Country:US
Mailing Address - Phone:334-793-6511
Mailing Address - Fax:334-793-4697
Practice Address - Street 1:4300 W MAIN ST
Practice Address - Street 2:SUITE 31
Practice Address - City:DOTHAN
Practice Address - State:AL
Practice Address - Zip Code:36305-1054
Practice Address - Country:US
Practice Address - Phone:334-793-6511
Practice Address - Fax:334-793-4697
Is Sole Proprietor?:No
Enumeration Date:2006-10-11
Last Update Date:2010-03-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AL00026481207V00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207V00000XAllopathic & Osteopathic PhysiciansObstetrics & Gynecology
Provider Identifiers
StateIdentifier IDID TypeIssuer
AL009910756Medicaid
510I160023Medicare PIN
OTH000Medicare UPIN