Provider Demographics
NPI:1760495824
Name:JOHNSON, RURIK
Entity Type:Individual
Prefix:DR
First Name:RURIK
Middle Name:
Last Name:JOHNSON
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:550 ORCHARD PARK RD
Mailing Address - Street 2:A103
Mailing Address - City:WEST SENECA
Mailing Address - State:NY
Mailing Address - Zip Code:14224-2646
Mailing Address - Country:US
Mailing Address - Phone:716-677-5500
Mailing Address - Fax:716-677-5008
Practice Address - Street 1:550 ORCHARD PARK RD
Practice Address - Street 2:A103
Practice Address - City:WEST SENECA
Practice Address - State:NY
Practice Address - Zip Code:14224-2646
Practice Address - Country:US
Practice Address - Phone:716-677-5500
Practice Address - Fax:716-677-5008
Is Sole Proprietor?:No
Enumeration Date:2006-08-13
Last Update Date:2009-12-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY229457208600000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208600000XAllopathic & Osteopathic PhysiciansSurgery
Provider Identifiers
StateIdentifier IDID TypeIssuer
00028110301OtherUNIVERA
0156830OtherGHI PPO
000529158001OtherBC/BS
NYP00474579OtherRRM
NY229457-7WOtherWORKERS COMPENSATION
NY02877796Medicaid
1714218OtherINDEPENDENT HEALTH
000529158001OtherBC/BS