Provider Demographics
NPI:1952820912
Name:JOHNSTON, MALCOLM A IV
Entity Type:Individual
Prefix:
First Name:MALCOLM
Middle Name:A
Last Name:JOHNSTON
Suffix:IV
Gender:M
Credentials:
Other - Prefix:MR
Other - First Name:MALCOLM
Other - Middle Name:A
Other - Last Name:JOHNSTON
Other - Suffix:IV
Other - Last Name Type:Professional Name
Other - Credentials:
Mailing Address - Street 1:133 N RIVER ST
Mailing Address - Street 2:
Mailing Address - City:WILKES BARRE
Mailing Address - State:PA
Mailing Address - Zip Code:18711-0800
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:133 N RIVER ST
Practice Address - Street 2:
Practice Address - City:WILKES BARRE
Practice Address - State:PA
Practice Address - Zip Code:18711-0800
Practice Address - Country:US
Practice Address - Phone:570-208-5900
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2017-09-11
Last Update Date:2017-09-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
PA390200000X
2255A2300X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2255A2300XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersSpecialist/TechnologistAthletic Trainer
No390200000XStudent, Health CareStudent in an Organized Health Care Education/Training Program