Provider Demographics
NPI:1922182856
Name:JOHNSTON, MARY
Entity Type:Individual
Prefix:
First Name:MARY
Middle Name:
Last Name:JOHNSTON
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:711 TROY SCHENECTADY RD
Mailing Address - Street 2:SUITE 203
Mailing Address - City:LATHAM
Mailing Address - State:NY
Mailing Address - Zip Code:12110-2442
Mailing Address - Country:US
Mailing Address - Phone:518-782-3700
Mailing Address - Fax:518-782-3799
Practice Address - Street 1:391 MYRTLE AVENUE
Practice Address - Street 2:SUITE 4A
Practice Address - City:ALBANY
Practice Address - State:NY
Practice Address - Zip Code:12208
Practice Address - Country:US
Practice Address - Phone:518-207-2273
Practice Address - Fax:518-207-2293
Is Sole Proprietor?:No
Enumeration Date:2006-10-25
Last Update Date:2015-12-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY167722207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
NY01054966Medicaid
NY01054966Medicaid
NYE41061Medicare UPIN
NYCC8882Medicare PIN