Basic Information
| Provider Information | |||||||||
| NPI: | 1558348714 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | JOHNSTON | ||||||||
| FirstName: | MARTHA | ||||||||
| MiddleName: | ANNE | ||||||||
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| Credential: | MD | ||||||||
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| Mailing Information | |||||||||
| Address1: | 415 BYERS RD | ||||||||
| Address2: | STE 300 | ||||||||
| City: | MIAMISBURG | ||||||||
| State: | OH | ||||||||
| PostalCode: | 453423684 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 9378662494 | ||||||||
| FaxNumber: | 9378668494 | ||||||||
| Practice Location | |||||||||
| Address1: | 415 BYERS RD | ||||||||
| Address2: | STE 300 | ||||||||
| City: | MIAMISBURG | ||||||||
| State: | OH | ||||||||
| PostalCode: | 453423684 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 9378662494 | ||||||||
| FaxNumber: | 9378668494 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 12/29/2005 | ||||||||
| LastUpdateDate: | 01/20/2021 | ||||||||
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| ProviderGenderCode: | F | ||||||||
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| IsSoleProprietor: | N | ||||||||
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| NPICertificationDate: | 01/20/2021 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 207P00000X | 35.050078 | OH | N | Allopathic & Osteopathic Physicians | Emergency Medicine | 207Q00000X | 35050078J | OH | Y | Allopathic & Osteopathic Physicians | Family Medicine |
ID Information
| ID | Type | State | Issuer | Description | JO0658682 | 01 | OH | MEDICARE PTAN | OTHER | 0658681 | 01 | OH | MEDICARE PTAN | OTHER | 0658686 | 01 | OH | MEDICARE PTAN | OTHER | 153891 | 05 | OH | MEDICAID |