Healthcare Provider Details

I. General information

NPI: 1851398168
Provider Name (Legal Business Name): MARK EDMUND JOHNSTON MD FRCSC
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 06/30/2005
Last Update Date: 03/06/2023
Certification Date: 03/06/2023
Deactivation Date:
Reactivation Date:

III. Provider practice location address

13330 N 74TH ST
OMAHA NE
68122-1919
US

IV. Provider business mailing address

13330 N 74TH ST
OMAHA NE
68122-1919
US

V. Phone/Fax

Practice location:
  • Phone: 402-639-3250
  • Fax: 402-387-7967
Mailing address:
  • Phone: 26-393-2504
  • Fax: 402-397-7967

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code207W00000X
TaxonomyOphthalmology Physician
License Number31743
License Number StateIA
# 2
Primary TaxonomyY
Taxonomy Code207W00000X
TaxonomyOphthalmology Physician
License Number20412
License Number StateNE

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: