Provider Demographics
NPI:1366706525
Name:JOHNSON, RYAN (OD)
Entity type:Individual
Prefix:
First Name:RYAN
Middle Name:
Last Name:JOHNSON
Suffix:
Gender:M
Credentials:OD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:7960 W RIFLEMAN ST
Mailing Address - Street 2:SUITE 150
Mailing Address - City:BOISE
Mailing Address - State:ID
Mailing Address - Zip Code:83704-9064
Mailing Address - Country:US
Mailing Address - Phone:208-377-8899
Mailing Address - Fax:
Practice Address - Street 1:7960 W RIFLEMAN ST
Practice Address - Street 2:SUITE 150
Practice Address - City:BOISE
Practice Address - State:ID
Practice Address - Zip Code:83704-9064
Practice Address - Country:US
Practice Address - Phone:208-377-8899
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2012-07-02
Last Update Date:2015-07-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA14467152W00000X
IDODP-100269152WV0400X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes152WV0400XEye and Vision Services ProvidersOptometristVision Therapy
No152W00000XEye and Vision Services ProvidersOptometrist