Healthcare Provider Details

I. General information

NPI: 1215967856
Provider Name (Legal Business Name): JOHNNY JOHNSTON MD
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 07/03/2006
Last Update Date: 07/02/2013
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1401 E VAN BUREN AVE
MCALESTER OK
74501-4245
US

IV. Provider business mailing address

6600 S YALE AVE SUITE 1400
TULSA OK
74136-3347
US

V. Phone/Fax

Practice location:
  • Phone: 918-426-0240
  • Fax: 918-423-4051
Mailing address:
  • Phone: 918-488-6001
  • Fax: 918-488-6010

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code208000000X
TaxonomyPediatrics Physician
License Number37489
License Number StateIA
# 2
Primary TaxonomyY
Taxonomy Code208000000X
TaxonomyPediatrics Physician
License Number29774
License Number StateOK

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: