Provider Demographics
NPI:1033800412
Name:JOHNSON, RYAN BRUCE (DO)
Entity Type:Individual
Prefix:DR
First Name:RYAN
Middle Name:BRUCE
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 1:19400 MC KINLEY CT
Mailing Address - Street 2:
Mailing Address - City:SHOREWOOD
Mailing Address - State:MN
Mailing Address - Zip Code:55331-8119
Mailing Address - Country:US
Mailing Address - Phone:651-328-3717
Mailing Address - Fax:
Practice Address - Street 1:1750 W HARRISON ST STE 739
Practice Address - Street 2:
Practice Address - City:CHICAGO
Practice Address - State:IL
Practice Address - Zip Code:60612-3825
Practice Address - Country:US
Practice Address - Phone:312-942-3134
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2023-05-17
Last Update Date:2023-05-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL125.081706207L00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207L00000XAllopathic & Osteopathic PhysiciansAnesthesiology