Basic Information
| Provider Information | |||||||||
| NPI: | 1982866109 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | JOHNSTON | ||||||||
| FirstName: | GREGORY | ||||||||
| MiddleName: | ROSS | ||||||||
| NamePrefix: | DR. | ||||||||
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| Credential: | D.O. | ||||||||
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| Mailing Information | |||||||||
| Address1: | 2200 JEFFERSON AVE | ||||||||
| Address2: | 5TH FL | ||||||||
| City: | TOLEDO | ||||||||
| State: | OH | ||||||||
| PostalCode: | 436047101 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 4192518983 | ||||||||
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| Practice Location | |||||||||
| Address1: | 3930 SUNFOREST CT | ||||||||
| Address2: | 100 | ||||||||
| City: | TOLEDO | ||||||||
| State: | OH | ||||||||
| PostalCode: | 436234527 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 4192518760 | ||||||||
| FaxNumber: | 4192518765 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 06/29/2008 | ||||||||
| LastUpdateDate: | 11/19/2015 | ||||||||
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| ProviderGenderCode: | M | ||||||||
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| IsSoleProprietor: | Y | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 208600000X | 5101017786 | MI | N | Allopathic & Osteopathic Physicians | Surgery | 208600000X | 34.011316 | OH | Y | Allopathic & Osteopathic Physicians | Surgery |
ID Information
| ID | Type | State | Issuer | Description | 0105812 | 05 | OH | MEDICAID |