Provider Demographics
NPI:1548253768
Name:JOHNSTON, WILLIAM R (OPTICIAN)
Entity type:Individual
Prefix:
First Name:WILLIAM
Middle Name:R
Last Name:JOHNSTON
Suffix:
Gender:M
Credentials:OPTICIAN
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:7324 CALUMET AVE
Mailing Address - Street 2:
Mailing Address - City:HAMMOND
Mailing Address - State:IN
Mailing Address - Zip Code:46324-2620
Mailing Address - Country:US
Mailing Address - Phone:219-931-3314
Mailing Address - Fax:
Practice Address - Street 1:7324 CALUMET AVE
Practice Address - Street 2:
Practice Address - City:HAMMOND
Practice Address - State:IN
Practice Address - Zip Code:46324-2620
Practice Address - Country:US
Practice Address - Phone:219-931-3314
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2005-08-23
Last Update Date:2008-02-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
N/A156FX1800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes156FX1800XEye and Vision Services ProvidersTechnician/TechnologistOptician
Provider Identifiers
StateIdentifier IDID TypeIssuer
IN0162850001Medicare NSC