Provider Demographics
NPI:1124048079
Name:JOHNSTON, DOUGLAS THOMAS (DO)
Entity type:Individual
Prefix:
First Name:DOUGLAS
Middle Name:THOMAS
Last Name:JOHNSTON
Suffix:
Gender:M
Credentials:DO
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:300 E MCBEE AVE FL 4
Mailing Address - Street 2:
Mailing Address - City:GREENVILLE
Mailing Address - State:SC
Mailing Address - Zip Code:29601-2842
Mailing Address - Country:US
Mailing Address - Phone:864-522-8603
Mailing Address - Fax:
Practice Address - Street 1:200 PATEWOOD DR STE A140
Practice Address - Street 2:
Practice Address - City:GREENVILLE
Practice Address - State:SC
Practice Address - Zip Code:29615-3585
Practice Address - Country:US
Practice Address - Phone:864-454-5125
Practice Address - Fax:864-241-9201
Is Sole Proprietor?:No
Enumeration Date:2006-07-20
Last Update Date:2022-08-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NC2011-01906207K00000X
SC967207K00000X
ALDO840207K00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207K00000XAllopathic & Osteopathic PhysiciansAllergy & Immunology
Provider Identifiers
StateIdentifier IDID TypeIssuer
NC5920097Medicaid
SCPENDINGMedicaid
SC009671Medicaid
SCI10980Medicare UPIN
SC009671Medicaid
SCI109806910Medicare PIN