Provider Demographics
NPI:1730182239
Name:JOHNSTON, RANDOLPH LEIGH (MD)
Entity type:Individual
Prefix:DR
First Name:RANDOLPH
Middle Name:LEIGH
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 1:1300 E 20TH ST
Mailing Address - Street 2:
Mailing Address - City:CHEYENNE
Mailing Address - State:WY
Mailing Address - Zip Code:82001-4021
Mailing Address - Country:US
Mailing Address - Phone:307-634-2020
Mailing Address - Fax:307-635-6510
Practice Address - Street 1:1300 E 20TH ST
Practice Address - Street 2:
Practice Address - City:CHEYENNE
Practice Address - State:WY
Practice Address - Zip Code:82001-4021
Practice Address - Country:US
Practice Address - Phone:307-634-2020
Practice Address - Fax:307-635-6510
Is Sole Proprietor?:No
Enumeration Date:2005-05-27
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WY3308A207W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207W00000XAllopathic & Osteopathic PhysiciansOphthalmology
Provider Identifiers
StateIdentifier IDID TypeIssuer
WY104145200Medicaid
306588Medicare ID - Type Unspecified
WY104145200Medicaid