=====================================================
General NPI Number Information
=====================================================
NPI Number | 1992844708
-----------------------------------------------------
Entity Type | Individual
-----------------------------------------------------
Provider Name | LELAND MANN JOHNSTON JR. M.D.
-----------------------------------------------------
Gender | Male
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 02/06/2007
-----------------------------------------------------
Last Update Date | 01/25/2008
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 1740 SUMAC AVE
-----------------------------------------------------
City | BOULDER
-----------------------------------------------------
State | CO
-----------------------------------------------------
Zip | 80304-0814
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 720-565-1422
-----------------------------------------------------
Fax | 866-849-7805
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 1740 SUMAC AVE
-----------------------------------------------------
City | BOULDER
-----------------------------------------------------
State | CO
-----------------------------------------------------
Zip | 80304-0814
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 720-565-1422
-----------------------------------------------------
Fax | 866-849-7805
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position |
-----------------------------------------------------
Name |
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone |
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 2084P0800X
-----------------------------------------------------
Taxonomy Name | Psychiatry Physician
-----------------------------------------------------
License Number | 38458
-----------------------------------------------------
License Number State | CO
-----------------------------------------------------