Provider Demographics
NPI:1700896263
Name:JOHNSTON, LEWIS DUBARD (MD)
Entity Type:Individual
Prefix:
First Name:LEWIS
Middle Name:DUBARD
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 1:965 RIDGE LAKE BLVD STE 103
Mailing Address - Street 2:
Mailing Address - City:MEMPHIS
Mailing Address - State:TN
Mailing Address - Zip Code:38120-9446
Mailing Address - Country:US
Mailing Address - Phone:901-227-3255
Mailing Address - Fax:901-227-8591
Practice Address - Street 1:2173 MAIN ST
Practice Address - Street 2:
Practice Address - City:MADISON
Practice Address - State:MS
Practice Address - Zip Code:39110-6309
Practice Address - Country:US
Practice Address - Phone:601-605-3858
Practice Address - Fax:601-605-3898
Is Sole Proprietor?:No
Enumeration Date:2006-08-08
Last Update Date:2018-03-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MS15001207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
MS00119937Medicaid
MSG03129Medicare UPIN
MS080002805Medicare PIN