Provider Demographics
NPI:1912990458
Name:JOHNSTON, SCOTT L (MD)
Entity Type:Individual
Prefix:
First Name:SCOTT
Middle Name:L
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:PO BOX 689
Mailing Address - Street 2:
Mailing Address - City:WRIGHT
Mailing Address - State:WY
Mailing Address - Zip Code:82732-0689
Mailing Address - Country:US
Mailing Address - Phone:307-660-8699
Mailing Address - Fax:307-686-2602
Practice Address - Street 1:801 E 4TH ST STE 20
Practice Address - Street 2:
Practice Address - City:GILLETTE
Practice Address - State:WY
Practice Address - Zip Code:82716-4061
Practice Address - Country:US
Practice Address - Phone:307-686-2600
Practice Address - Fax:307-686-2602
Is Sole Proprietor?:Yes
Enumeration Date:2005-08-30
Last Update Date:2021-02-25
Deactivation Date:2006-03-23
Deactivation Code:
Reactivation Date:2006-04-03
Provider Licenses
StateLicense IDTaxonomies
WY6083A207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
WY113554600Medicaid
WYG07344Medicare UPIN
WY304810Medicare ID - Type Unspecified