Provider Demographics
NPI:1356791545
Name:JOHNSTON, SHANE (OD)
Entity type:Individual
Prefix:DR
First Name:SHANE
Middle Name:
Last Name:JOHNSTON
Suffix:
Gender:M
Credentials:OD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:11333 N 92ND ST
Mailing Address - Street 2:#1001
Mailing Address - City:SCOTTSDALE
Mailing Address - State:AZ
Mailing Address - Zip Code:85260-6106
Mailing Address - Country:US
Mailing Address - Phone:623-688-7310
Mailing Address - Fax:
Practice Address - Street 1:7014 E CAMELBACK RD
Practice Address - Street 2:SUITE #590
Practice Address - City:SCOTTSDALE
Practice Address - State:AZ
Practice Address - Zip Code:85251-1227
Practice Address - Country:US
Practice Address - Phone:480-840-0333
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2016-06-17
Last Update Date:2016-06-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AZ2108152W00000X, 152WS0006X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes152W00000XEye and Vision Services ProvidersOptometrist
No152WS0006XEye and Vision Services ProvidersOptometristSports Vision