1982692307 NPI number — DR. MATTHEW D JOHNSTON MD

Table of content: DR. MATTHEW D JOHNSTON MD (NPI 1982692307)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1982692307 NPI number — DR. MATTHEW D JOHNSTON MD

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
Provider Last Name:
JOHNSTON
Provider First Name:
MATTHEW
Provider Middle Name:
D
Provider Name Prefix Text:
DR.
Provider Name Suffix Text:
Provider Credential Text:
MD
Provider Gender Code:
M

Provider's Other Name Information

Provider Other Organization Name:
Provider Other Organization Name Type Code:
Provider Other Last Name:
Provider Other First Name:
Provider Other Middle Name:
Provider Other Name Prefix Text:
Provider Other Name Suffix Text:
Provider Other Credential Text:
Provider Other Last Name Type Code:

NPI Number Information

NPI Number:
1982692307
Entity Type Code:
Individual
Replacement NPI:
Last Update Date:
11/16/2017
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
1255 EAST 3900 SOUTH
Provider Second Line Business Mailing Address:
SUITE 300
Provider Business Mailing Address City Name:
SALT LAKE CITY
Provider Business Mailing Address State Name:
UT
Provider Business Mailing Address Postal Code:
84124
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
918-488-6001
Provider Business Mailing Address Fax Number:

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
1255 EAST 3900 SOUTH
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
SALT LAKE CITY
Provider Business Practice Location Address State Name:
UT
Provider Business Practice Location Address Postal Code:
84124
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
918-272-2247
Provider Business Practice Location Address Fax Number:
Provider Enumeration Date:
10/10/2005

Additional Information

			
		

Authorized Official

Authorized Official Last Name:
Authorized Official First Name:
Authorized Official Middle Name:
Authorized Official Title or Position:
Authorized Official Telephone Number:

Provider Taxonomy Codes

  • Taxonomy code: 207Q00000X , with the licence number:  20266 , registered in the state of OK ; information, associated with the NPI states the following Primary Taxonomy Switch: "N" .
  • Taxonomy code: 207Q00000X , with the licence number: 9824877-1205 , registered in the state of UT ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

Other Provider's Identifiers (legacy, non-NPI)

  • Identifier: 100091330A , issued by the state of ( OK ) . This identifiers is of the category "MEDICAID".
  • Identifier: 500522075 . This is a "MEDICARE GROUP PIN" identifier , issued by the state of ( OK ) . This identifiers is of the category "OTHER".