Provider Demographics
NPI:1811963283
Name:JOHNSTON, JAMES GILLIAM II (MD)
Entity type:Individual
Prefix:
First Name:JAMES
Middle Name:GILLIAM
Last Name:JOHNSTON
Suffix:II
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:J.
Other - Middle Name:GILLIAM
Other - Last Name:JOHNSTON
Other - Suffix:
Other - Last Name Type:Professional Name
Other - Credentials:MD
Mailing Address - Street 1:1 MEDICAL CENTER DR
Mailing Address - Street 2:DHMC FAMILY MEDICINE
Mailing Address - City:LEBANON
Mailing Address - State:NH
Mailing Address - Zip Code:03756-1000
Mailing Address - Country:US
Mailing Address - Phone:603-650-4000
Mailing Address - Fax:
Practice Address - Street 1:18 OLD ETNA RD
Practice Address - Street 2:DHMC - FAMILY MEDICINE
Practice Address - City:LEBANON
Practice Address - State:NH
Practice Address - Zip Code:03766
Practice Address - Country:US
Practice Address - Phone:603-650-4000
Practice Address - Fax:603-650-4198
Is Sole Proprietor?:No
Enumeration Date:2006-02-27
Last Update Date:2012-12-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NH14733207Q00000X
VT042-0011922207Q00000X
ME012982207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
VT1017549Medicaid
ME315300099Medicaid
NH30209510Medicaid
VT1017549Medicaid
NH30209510Medicaid
NH001574803Medicare PIN
VT001574801Medicare PIN
MEMM3592Medicare PIN
ME080179999Medicare PIN