Provider Demographics
NPI:1184653404
Name:JOHNSON, RYAN SCOTT (OD)
Entity Type:Individual
Prefix:DR
First Name:RYAN
Middle Name:SCOTT
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 1:12482 DALLIN RD
Mailing Address - Street 2:
Mailing Address - City:POCATELLO
Mailing Address - State:ID
Mailing Address - Zip Code:83202-5073
Mailing Address - Country:US
Mailing Address - Phone:208-241-9145
Mailing Address - Fax:208-238-2069
Practice Address - Street 1:4240 YELLOWSTONE AVE
Practice Address - Street 2:
Practice Address - City:CHUBBUCK
Practice Address - State:ID
Practice Address - Zip Code:83202-2420
Practice Address - Country:US
Practice Address - Phone:208-238-2020
Practice Address - Fax:208-238-2069
Is Sole Proprietor?:No
Enumeration Date:2006-06-30
Last Update Date:2021-07-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IDODP-1037152W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes152W00000XEye and Vision Services ProvidersOptometrist
Provider Identifiers
StateIdentifier IDID TypeIssuer
ID807153600Medicaid
1594433Medicare ID - Type Unspecified
ID807153600Medicaid