Provider Demographics
NPI:1992711030
Name:JOHNSTON, WILLIAM (MD)
Entity type:Individual
Prefix:
First Name:WILLIAM
Middle Name:
Last Name:JOHNSTON
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:20952 E 12 MILE RD
Mailing Address - Street 2:SUITE 200
Mailing Address - City:SAINT CLAIR SHORES
Mailing Address - State:MI
Mailing Address - Zip Code:48081-3200
Mailing Address - Country:US
Mailing Address - Phone:586-771-4820
Mailing Address - Fax:586-771-6620
Practice Address - Street 1:33014 5 MILE RD
Practice Address - Street 2:
Practice Address - City:LIVONIA
Practice Address - State:MI
Practice Address - Zip Code:48154-3075
Practice Address - Country:US
Practice Address - Phone:734-261-7401
Practice Address - Fax:734-261-7410
Is Sole Proprietor?:No
Enumeration Date:2006-07-31
Last Update Date:2019-10-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL036111816208800000X
MI4301081273208800000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208800000XAllopathic & Osteopathic PhysiciansUrology
Provider Identifiers
StateIdentifier IDID TypeIssuer
MI0219690004Medicare NSC
MI0E06273Medicare PIN
H94868Medicare UPIN