Provider Demographics
NPI:1093948259
Name:JOHNSON, RYAN DANIEL (OD)
Entity Type:Individual
Prefix:MR
First Name:RYAN
Middle Name:DANIEL
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 1:8362 TAMARACK VILLAGE
Mailing Address - Street 2:RM 108
Mailing Address - City:WOODBURY
Mailing Address - State:MN
Mailing Address - Zip Code:55125-3392
Mailing Address - Country:US
Mailing Address - Phone:651-730-9662
Mailing Address - Fax:
Practice Address - Street 1:8362 TAMARACK VILLAGE
Practice Address - Street 2:RM 108
Practice Address - City:WOODBURY
Practice Address - State:MN
Practice Address - Zip Code:55125-3392
Practice Address - Country:US
Practice Address - Phone:651-730-9662
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2009-09-03
Last Update Date:2009-09-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MNMN-3176152W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes152W00000XEye and Vision Services ProvidersOptometrist