Provider Demographics
NPI:1750718979
Name:JOHNSTON, ROGER DALE JR
Entity type:Individual
Prefix:MR
First Name:ROGER
Middle Name:DALE
Last Name:JOHNSTON
Suffix:JR
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:160 KEONEKAI RD APT 27-206
Mailing Address - Street 2:
Mailing Address - City:KIHEI
Mailing Address - State:HI
Mailing Address - Zip Code:96753-7145
Mailing Address - Country:US
Mailing Address - Phone:801-592-6432
Mailing Address - Fax:
Practice Address - Street 1:160 KEONEKAI RD APT 27-206
Practice Address - Street 2:
Practice Address - City:KIHEI
Practice Address - State:HI
Practice Address - Zip Code:96753-7145
Practice Address - Country:US
Practice Address - Phone:801-592-6432
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2013-10-02
Last Update Date:2023-11-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes251S00000XAgenciesCommunity/Behavioral Health