Provider Demographics
NPI:1982692307
Name:JOHNSTON, MATTHEW D (MD)
Entity Type:Individual
Prefix:DR
First Name:MATTHEW
Middle Name:D
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 1:1255 EAST 3900 SOUTH
Mailing Address - Street 2:SUITE 300
Mailing Address - City:SALT LAKE CITY
Mailing Address - State:UT
Mailing Address - Zip Code:84124
Mailing Address - Country:US
Mailing Address - Phone:918-488-6001
Mailing Address - Fax:
Practice Address - Street 1:1255 EAST 3900 SOUTH
Practice Address - Street 2:
Practice Address - City:SALT LAKE CITY
Practice Address - State:UT
Practice Address - Zip Code:84124
Practice Address - Country:US
Practice Address - Phone:918-272-2247
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2005-10-10
Last Update Date:2017-11-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OK20266207Q00000X
UT9824877-1205207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
OK100091330AMedicaid
OK500522075OtherMEDICARE GROUP PIN
OK100091330AMedicaid
OKG51825Medicare UPIN