Provider Demographics
NPI:1891704615
Name:JOHNSTON, GLENN A (OD)
Entity Type:Individual
Prefix:
First Name:GLENN
Middle Name:A
Last Name:JOHNSTON
Suffix:
Gender:M
Credentials:OD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2565 CEANOTHUS AVE
Mailing Address - Street 2:STE 155
Mailing Address - City:CHICO
Mailing Address - State:CA
Mailing Address - Zip Code:95973-7615
Mailing Address - Country:US
Mailing Address - Phone:530-899-3939
Mailing Address - Fax:
Practice Address - Street 1:2565 CEANOTHUS AVE
Practice Address - Street 2:STE 155
Practice Address - City:CHICO
Practice Address - State:CA
Practice Address - Zip Code:95973-7615
Practice Address - Country:US
Practice Address - Phone:530-899-3939
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2006-08-08
Last Update Date:2008-06-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA6257 TPL152W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes152W00000XEye and Vision Services ProvidersOptometrist
Provider Identifiers
StateIdentifier IDID TypeIssuer
CASD0062570Medicaid
CAT10274Medicare UPIN
CASD0062570Medicare PIN
CASD0062570Medicaid