Provider Demographics
NPI:1891732616
Name:ALSTON-JOHNSON, DEVENA E (MD)
Entity Type:Individual
Prefix:
First Name:DEVENA
Middle Name:E
Last Name:ALSTON-JOHNSON
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 1:348 VINTAGE POINT LN
Mailing Address - Street 2:
Mailing Address - City:WENDELL
Mailing Address - State:NC
Mailing Address - Zip Code:27591-6858
Mailing Address - Country:US
Mailing Address - Phone:219-380-1257
Mailing Address - Fax:
Practice Address - Street 1:720 MALCOLM BLVD
Practice Address - Street 2:
Practice Address - City:CONNELLY SPRINGS
Practice Address - State:NC
Practice Address - Zip Code:28612-7920
Practice Address - Country:US
Practice Address - Phone:864-546-3699
Practice Address - Fax:864-546-3680
Is Sole Proprietor?:No
Enumeration Date:2006-06-01
Last Update Date:2021-10-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
SC32825207RH0003X
IN01040872A207RH0003X
NC2008-01388207RH0003X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207RH0003XAllopathic & Osteopathic PhysiciansInternal MedicineHematology & Oncology
Provider Identifiers
StateIdentifier IDID TypeIssuer
NCNCMedicaid
SC328257Medicaid
SC328257Medicaid
SCAA5593Medicare PIN
SC8157Medicare PIN
INF01651Medicare UPIN
IN114620YYMedicare PIN
INP00652478Medicare PIN