Provider Demographics
NPI:1972181519
Name:JOHNSON, RYAN (DO)
Entity type:Individual
Prefix:DR
First Name:RYAN
Middle Name:
Last Name:JOHNSON
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 1:2021 PROFESSIONAL CENTER DR STE 100
Mailing Address - Street 2:
Mailing Address - City:ORANGE PARK
Mailing Address - State:FL
Mailing Address - Zip Code:32073-4461
Mailing Address - Country:US
Mailing Address - Phone:049-622-9200
Mailing Address - Fax:904-622-9188
Practice Address - Street 1:2021 PROFESSIONAL CENTER DR STE 100
Practice Address - Street 2:
Practice Address - City:ORANGE PARK
Practice Address - State:FL
Practice Address - Zip Code:32073-4461
Practice Address - Country:US
Practice Address - Phone:049-622-9200
Practice Address - Fax:904-622-9188
Is Sole Proprietor?:Yes
Enumeration Date:2021-04-01
Last Update Date:2025-06-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLUO8151207Q00000X
390200000X
FL56876207R00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207R00000XAllopathic & Osteopathic PhysiciansInternal Medicine
No207Q00000XAllopathic & Osteopathic PhysiciansFamily MedicineGroup - Single Specialty
No390200000XStudent, Health CareStudent in an Organized Health Care Education/Training Program