Healthcare Provider Details

I. General information

NPI: 1487676821
Provider Name (Legal Business Name): KEVIN JOHNSTON MD
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 07/24/2006
Last Update Date: 02/06/2014
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

559 W WASHINGTON ST
BURNS OR
97720-1441
US

IV. Provider business mailing address

559 W WASHINGTON ST
BURNS OR
97720-1441
US

V. Phone/Fax

Practice location:
  • Phone: 541-573-2074
  • Fax: 541-573-8893
Mailing address:
  • Phone: 541-573-2074
  • Fax: 541-573-8893

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207Q00000X
TaxonomyFamily Medicine Physician
License NumberMD23974
License Number StateOR

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: