Provider Demographics
NPI:1487690608
Name:JOHNSTONE, THEODORE RELDON (MD)
Entity type:Individual
Prefix:MR
First Name:THEODORE
Middle Name:RELDON
Last Name:JOHNSTONE
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 1:1290 E. ALMOND AVE.
Mailing Address - Street 2:
Mailing Address - City:MADERA
Mailing Address - State:CA
Mailing Address - Zip Code:93637-5606
Mailing Address - Country:US
Mailing Address - Phone:559-661-6212
Mailing Address - Fax:559-661-6216
Practice Address - Street 1:1290 E. ALMOND AVE.
Practice Address - Street 2:
Practice Address - City:MADERA
Practice Address - State:CA
Practice Address - Zip Code:93637-5606
Practice Address - Country:US
Practice Address - Phone:559-661-6212
Practice Address - Fax:559-661-6216
Is Sole Proprietor?:No
Enumeration Date:2006-06-22
Last Update Date:2012-11-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAA19140208D00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208D00000XAllopathic & Osteopathic PhysiciansGeneral Practice
Provider Identifiers
StateIdentifier IDID TypeIssuer
ZZZ994837Medicare PIN
A21614Medicare UPIN