MEDICARE: DR. GARY ERLE JOHNSTON D.O.

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	207QA0505X	Adult Medicine Physician	OK1230	OK

General Provider Information

NPI Number	:	1962537902
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	DR. GARY ERLE JOHNSTON D.O.

Provider Business Mailing Address
First Line	:	1501 COTTONWOOD DR
Second Line	:
City	:	POTEAU
State	:	OK
Zip	:	74953-2048
Country	:	US
Telephone Number	:	918-647-7171
Fax Number	:

Provider Business Practice Location Address
First Line	:	53468 MINERAL SPRINGS RD
Second Line	:
City	:	HODGEN
State	:	OK
Zip	:	74939-3064
Country	:	US
Telephone Number	:	918-653-7831
Fax Number	:

Authorized Official
Title or Position	:
Name	:
Credential	:
Telephone Number	:

Provider Enumeration Date	:	02/22/2007
Last Update Date	:	07/09/2007

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