Provider Demographics
NPI:1922058577
Name:JOHNSTON, RENATE A (MD)
Entity Type:Individual
Prefix:
First Name:RENATE
Middle Name:A
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 1:4750 HEMPSTEAD STATION DR
Mailing Address - Street 2:
Mailing Address - City:KETTERING
Mailing Address - State:OH
Mailing Address - Zip Code:45429-5164
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:1343 N FOUNTAIN BLVD
Practice Address - Street 2:
Practice Address - City:SPRINGFIELD
Practice Address - State:OH
Practice Address - Zip Code:45504-1422
Practice Address - Country:US
Practice Address - Phone:937-390-5000
Practice Address - Fax:937-390-5526
Is Sole Proprietor?:No
Enumeration Date:2006-05-12
Last Update Date:2008-05-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OH35062184J207P00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207P00000XAllopathic & Osteopathic PhysiciansEmergency Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
OH0863954Medicaid
OH000000302753OtherBCBS
P00088334OtherRAIL ROAD MEDICARE
OH0863954Medicaid
F17817Medicare UPIN
JO0825245Medicare PIN