Provider Demographics
NPI:1740367283
Name:JOHNSTON, MICHAEL V (OD)
Entity type:Individual
Prefix:DR
First Name:MICHAEL
Middle Name:V
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 1:2110 12TH ST
Mailing Address - Street 2:
Mailing Address - City:HARLAN
Mailing Address - State:IA
Mailing Address - Zip Code:51537-2056
Mailing Address - Country:US
Mailing Address - Phone:712-755-2150
Mailing Address - Fax:712-755-7555
Practice Address - Street 1:2110 12TH ST
Practice Address - Street 2:
Practice Address - City:HARLAN
Practice Address - State:IA
Practice Address - Zip Code:51537-2056
Practice Address - Country:US
Practice Address - Phone:712-755-2150
Practice Address - Fax:712-755-7555
Is Sole Proprietor?:No
Enumeration Date:2006-11-01
Last Update Date:2008-05-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IA01898152W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes152W00000XEye and Vision Services ProvidersOptometrist
Provider Identifiers
StateIdentifier IDID TypeIssuer
IA1284455Medicaid
IA1284455Medicaid