Provider Demographics
NPI:1912975566
Name:JOHNSTON, SUSAN ELAINE (MD)
Entity Type:Individual
Prefix:
First Name:SUSAN
Middle Name:ELAINE
Last Name:JOHNSTON
Suffix:
Gender:F
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1272 GARRISON DR
Mailing Address - Street 2:
Mailing Address - City:MURFREESBORO
Mailing Address - State:TN
Mailing Address - Zip Code:37129-2598
Mailing Address - Country:US
Mailing Address - Phone:615-893-4480
Mailing Address - Fax:615-867-8182
Practice Address - Street 1:1272 GARRISON DR
Practice Address - Street 2:
Practice Address - City:MURFREESBORO
Practice Address - State:TN
Practice Address - Zip Code:37129-2598
Practice Address - Country:US
Practice Address - Phone:615-893-4480
Practice Address - Fax:615-867-8182
Is Sole Proprietor?:Yes
Enumeration Date:2006-03-09
Last Update Date:2020-06-26
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MS15521208000000X
TNMD42540208000000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208000000XAllopathic & Osteopathic PhysiciansPediatrics
Provider Identifiers
StateIdentifier IDID TypeIssuer
MS00120828Medicaid
MS370000284Medicare ID - Type Unspecified
MS00120828Medicaid