Provider Demographics
NPI:1790796654
Name:JOHNSON, ROBERT RYAN (DO)
Entity Type:Individual
Prefix:
First Name:ROBERT
Middle Name:RYAN
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:PO BOX 950248
Mailing Address - Street 2:
Mailing Address - City:LOUISVILLE
Mailing Address - State:KY
Mailing Address - Zip Code:40295-0248
Mailing Address - Country:US
Mailing Address - Phone:502-489-5730
Mailing Address - Fax:502-489-5753
Practice Address - Street 1:9070 DIXIE HWY
Practice Address - Street 2:SUITE 6
Practice Address - City:LOUISVILLE
Practice Address - State:KY
Practice Address - Zip Code:40258-1007
Practice Address - Country:US
Practice Address - Phone:502-271-3236
Practice Address - Fax:502-271-3356
Is Sole Proprietor?:No
Enumeration Date:2006-08-10
Last Update Date:2020-12-04
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IN11012923207Q00000X
KY03576207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
INP00377962Medicare PIN
IN048580M6Medicare PIN
KYK101340Medicare PIN