Healthcare Provider Details

I. General information

NPI: 1922082940
Provider Name (Legal Business Name): JACK C JOHNSTON M.D.
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 12/02/2005
Last Update Date: 04/07/2015
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2501 JIMMY JOHNSON BLVD SUITE 400
PT. ARTHUR TX
77640
US

IV. Provider business mailing address

3650 LAUREL STREET
BEAUMONT TX
77707
US

V. Phone/Fax

Practice location:
  • Phone: 409-838-0346
  • Fax: 409-839-3720
Mailing address:
  • Phone: 409-838-0346
  • Fax: 409-839-3720

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207XX0005X
TaxonomySports Medicine (Orthopaedic Surgery) Physician
License NumberK6025
License Number StateTX

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: