Healthcare Provider Details

I. General information

NPI: 1649618059
Provider Name (Legal Business Name): MARY J JOHNSTON DO
Entity Type: Individual
Gender: Female
Sole Proprietor: N

Provider Other Name: MARY J JOY

II. Dates (important events)

Enumeration Date: 06/07/2013
Last Update Date: 10/20/2025
Certification Date: 10/20/2025
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1919 LATHROP ST
FAIRBANKS AK
99701-5937
US

IV. Provider business mailing address

PO BOX 73720
FAIRBANKS AK
99707-3720
US

V. Phone/Fax

Practice location:
  • Phone: 907-458-2619
  • Fax: 907-374-1089
Mailing address:
  • Phone: 907-458-2619
  • Fax: 907-374-1089

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code207Q00000X
TaxonomyFamily Medicine Physician
License Number111064
License Number StateAK
# 2
Primary TaxonomyY
Taxonomy Code204D00000X
TaxonomyNeuromusculoskeletal Medicine & OMM Physician
License Number111064
License Number StateAK

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: