Provider Demographics
NPI:1649342445
Name:JOHNSTON, CLARISSA M (MD)
Entity type:Individual
Prefix:
First Name:CLARISSA
Middle Name:M
Last Name:JOHNSTON
Suffix:
Gender:F
Credentials:MD
Other - Prefix:
Other - First Name:CLARISSA
Other - Middle Name:MARY
Other - Last Name:FORAN
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:MD
Mailing Address - Street 1:1800 HARRISON ST FL 7
Mailing Address - Street 2:
Mailing Address - City:OAKLAND
Mailing Address - State:CA
Mailing Address - Zip Code:94612-3429
Mailing Address - Country:US
Mailing Address - Phone:510-625-6262
Mailing Address - Fax:
Practice Address - Street 1:601 E 15TH ST
Practice Address - Street 2:
Practice Address - City:AUSTIN
Practice Address - State:TX
Practice Address - Zip Code:78701-1930
Practice Address - Country:US
Practice Address - Phone:512-324-1000
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2006-11-15
Last Update Date:2015-10-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAA62097208M00000X
TXQ1181207RH0002X, 207R00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207RH0002XAllopathic & Osteopathic PhysiciansInternal MedicineHospice and Palliative Medicine
No208M00000XAllopathic & Osteopathic PhysiciansHospitalist
No207R00000XAllopathic & Osteopathic PhysiciansInternal Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
CA00A620970Medicaid
TX341861801Medicaid
TX376999YMGJMedicare PIN
00A620970Medicare ID - Type Unspecified
CA00A620970Medicaid