Healthcare Provider Details

I. General information

NPI: 1962865691
Provider Name (Legal Business Name): JERRY LAMAR JOHNSTON JR. MD
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 03/31/2016
Last Update Date: 10/05/2023
Certification Date: 10/05/2023
Deactivation Date:
Reactivation Date:

III. Provider practice location address

309 JACKSON ST
MONROE LA
71201-7407
US

IV. Provider business mailing address

101 CATALPA ST
MONROE LA
71201-7418
US

V. Phone/Fax

Practice location:
  • Phone: 318-966-4000
  • Fax:
Mailing address:
  • Phone: 318-245-1863
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207L00000X
TaxonomyAnesthesiology Physician
License Number326872
License Number StateLA
# 2
Primary TaxonomyN
Taxonomy Code207L00000X
TaxonomyAnesthesiology Physician
License NumberE-13627
License Number StateAR
# 3
Primary TaxonomyN
Taxonomy Code207L00000X
TaxonomyAnesthesiology Physician
License Number85513
License Number StateSC

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: