Provider Demographics
NPI:1093771081
Name:JOHNSON, RON MICHAEL (MD)
Entity Type:Individual
Prefix:
First Name:RON
Middle Name:MICHAEL
Last Name:JOHNSON
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 1:580 LINCOLN PARK BLVD
Mailing Address - Street 2:SUITE 255
Mailing Address - City:KETTERING
Mailing Address - State:OH
Mailing Address - Zip Code:45429-3474
Mailing Address - Country:US
Mailing Address - Phone:937-949-8457
Mailing Address - Fax:937-949-8695
Practice Address - Street 1:580 LINCOLN PARK BLVD
Practice Address - Street 2:SUITE 255
Practice Address - City:KETTERING
Practice Address - State:OH
Practice Address - Zip Code:45429-3474
Practice Address - Country:US
Practice Address - Phone:937-949-8457
Practice Address - Fax:937-949-8695
Is Sole Proprietor?:No
Enumeration Date:2006-04-26
Last Update Date:2022-11-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OH350595172086S0122X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2086S0122XAllopathic & Osteopathic PhysiciansSurgeryPlastic and Reconstructive Surgery
Provider Identifiers
StateIdentifier IDID TypeIssuer
OH0878699Medicaid
G08002Medicare UPIN
0782742Medicare PIN