Basic Information
Provider Information | |||||||||
NPI: | 1215967856 | ||||||||
EntityType: | 1 | ||||||||
ReplacementNPI: |   | ||||||||
OrganizationName: |   | ||||||||
LastName: | JOHNSTON | ||||||||
FirstName: | JOHNNY | ||||||||
MiddleName: |   | ||||||||
NamePrefix: |   | ||||||||
NameSuffix: |   | ||||||||
Credential: | MD | ||||||||
OtherOrganizationName: |   | ||||||||
OtherOrganizationType: |   | ||||||||
OtherLastName: |   | ||||||||
OtherFirstName: |   | ||||||||
OtherMiddleName: |   | ||||||||
OtherNamePrefix: |   | ||||||||
OtherNameSuffix: |   | ||||||||
OtherCredential: |   | ||||||||
OtherLastNameType: |   | ||||||||
Mailing Information | |||||||||
Address1: | 6600 S YALE AVE | ||||||||
Address2: | SUITE 1400 | ||||||||
City: | TULSA | ||||||||
State: | OK | ||||||||
PostalCode: | 741363347 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 9184886001 | ||||||||
FaxNumber: | 9184886010 | ||||||||
Practice Location | |||||||||
Address1: | 1401 E VAN BUREN AVE | ||||||||
Address2: |   | ||||||||
City: | MCALESTER | ||||||||
State: | OK | ||||||||
PostalCode: | 745014245 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 9184260240 | ||||||||
FaxNumber: | 9184234051 | ||||||||
Other Information | |||||||||
ProviderEnumerationDate: | 07/03/2006 | ||||||||
LastUpdateDate: | 07/02/2013 | ||||||||
NPIDeactivationReasonCode: |   | ||||||||
NPIDeactivationDate: |   | ||||||||
NPIReactivationDate: |   | ||||||||
ProviderGenderCode: | M | ||||||||
AuthorizedOfficialLastName: |   | ||||||||
AuthorizedOfficialFirstName: |   | ||||||||
AuthorizedOfficialMiddleName: |   | ||||||||
AuthorizedOfficialTitleorPosition: |   | ||||||||
AuthorizedOfficialTelephone: |   | ||||||||
IsSoleProprietor: | N | ||||||||
IsOrganizationSubpart: |   | ||||||||
ParentOrganizationLBN: |   | ||||||||
AuthorizedOfficialNamePrefix: |   | ||||||||
AuthorizedOfficialNameSuffix: |   | ||||||||
AuthorizedOfficialCredential: |   | ||||||||
NPICertificationDate: |   |
Taxonomy Information
Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 208000000X | 37489 | IA | N |   | Allopathic & Osteopathic Physicians | Pediatrics |   | 208000000X | 29774 | OK | Y |   | Allopathic & Osteopathic Physicians | Pediatrics |   |
ID Information
ID | Type | State | Issuer | Description | 200484430A | 05 | OK |   | MEDICAID | 0278374 | 05 | IA |   | MEDICAID |