Healthcare Provider Details

I. General information

NPI: 1104429620
Provider Name (Legal Business Name): CHRISTIAN JOHNSTON
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 11/18/2020
Last Update Date: 11/18/2020
Certification Date: 11/18/2020
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1003 W SUNFLOWER RD
CLEVELAND MS
38733-0001
US

IV. Provider business mailing address

1005 LAMAR ST
CLEVELAND MS
38732-3102
US

V. Phone/Fax

Practice location:
  • Phone: 662-846-4280
  • Fax:
Mailing address:
  • Phone: 662-588-0665
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code2081S0010X
TaxonomySports Medicine (Physical Medicine & Rehabilitation) Physician
License NumberAT-0725
License Number StateMS

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: