Provider Demographics
NPI:1922465574
Name:JOHNSTON, SAMUEL ERVINE II (HIS)
Entity Type:Individual
Prefix:MR
First Name:SAMUEL
Middle Name:ERVINE
Last Name:JOHNSTON
Suffix:II
Gender:M
Credentials:HIS
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:9 SUTULA RD
Mailing Address - Street 2:
Mailing Address - City:SUFFIELD
Mailing Address - State:CT
Mailing Address - Zip Code:06078-2265
Mailing Address - Country:US
Mailing Address - Phone:860-916-6169
Mailing Address - Fax:860-906-3391
Practice Address - Street 1:9 SUTULA RD
Practice Address - Street 2:
Practice Address - City:SUFFIELD
Practice Address - State:CT
Practice Address - Zip Code:06078-2265
Practice Address - Country:US
Practice Address - Phone:860-916-6169
Practice Address - Fax:860-906-3391
Is Sole Proprietor?:Yes
Enumeration Date:2016-01-26
Last Update Date:2016-01-26
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CT440237700000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes237700000XSpeech, Language and Hearing Service ProvidersHearing Instrument Specialist