Healthcare Provider Details

I. General information

NPI: 1588851695
Provider Name (Legal Business Name): ROBERT MAYNARD JOHNSTON M.D.
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 10/02/2007
Last Update Date: 10/02/2007
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

515 LEE DALE DR
HEATHSVILLE VA
22473-4408
US

IV. Provider business mailing address

515 LEE DALE DR
HEATHSVILLE VA
22473-4408
US

V. Phone/Fax

Practice location:
  • Phone: 866-852-6069
  • Fax: 866-852-6069
Mailing address:
  • Phone: 866-852-6069
  • Fax: 866-852-6069

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207W00000X
TaxonomyOphthalmology Physician
License Number0101024628
License Number StateVA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: