Healthcare Provider Details

I. General information

NPI: 1538141668
Provider Name (Legal Business Name): MARILYN F.M. JOHNSTON M.D.
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 11/15/2005
Last Update Date: 04/20/2008
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

11133 DUNN RD DEPT. OF PATHOLOGY
SAINT LOUIS MO
63136-6119
US

IV. Provider business mailing address

PO BOX 144333
ORLANDO FL
32814-4333
US

V. Phone/Fax

Practice location:
  • Phone: 314-653-5630
  • Fax: 314-653-4099
Mailing address:
  • Phone: 407-422-9831
  • Fax: 407-648-2065

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207ZP0105X
TaxonomyClinical Pathology/Laboratory Medicine Physician
License NumberR7131
License Number StateMO
# 2
Primary TaxonomyN
Taxonomy Code207ZP0105X
TaxonomyClinical Pathology/Laboratory Medicine Physician
License Number
License Number StateIL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: