Provider Demographics
NPI:1952332181
Name:JOHNSTON, WALTER E (MD)
Entity Type:Individual
Prefix:
First Name:WALTER
Middle Name:E
Last Name:JOHNSTON
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1115 N FRONTAGE RD
Mailing Address - Street 2:
Mailing Address - City:VICKSBURG
Mailing Address - State:MS
Mailing Address - Zip Code:39180-5102
Mailing Address - Country:US
Mailing Address - Phone:601-634-8790
Mailing Address - Fax:
Practice Address - Street 1:1907 MISSION 66
Practice Address - Street 2:
Practice Address - City:VICKSBURG
Practice Address - State:MS
Practice Address - Zip Code:39180-3711
Practice Address - Country:US
Practice Address - Phone:601-636-1173
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2006-07-05
Last Update Date:2020-09-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MS07023207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
MS00014424Medicaid
MS5891536OtherAETNA
LA1141411Medicaid
MS00014424Medicaid
LA1141411Medicaid
MS080003291Medicare PIN
MS080166497Medicare PIN