Healthcare Provider Details

I. General information

NPI: 1487690608
Provider Name (Legal Business Name): THEODORE RELDON JOHNSTONE M.D.
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 06/22/2006
Last Update Date: 11/13/2012
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1290 E. ALMOND AVE.
MADERA CA
93637-5606
US

IV. Provider business mailing address

1290 E. ALMOND AVE.
MADERA CA
93637-5606
US

V. Phone/Fax

Practice location:
  • Phone: 559-661-6212
  • Fax: 559-661-6216
Mailing address:
  • Phone: 559-661-6212
  • Fax: 559-661-6216

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code208D00000X
TaxonomyGeneral Practice Physician
License NumberA19140
License Number StateCA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: