Provider Demographics
NPI:1184623878
Name:JOHNSON, RYAN DOUGLAS (MD)
Entity type:Individual
Prefix:
First Name:RYAN
Middle Name:DOUGLAS
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 1:2348 RAINBOWS END PT
Mailing Address - Street 2:
Mailing Address - City:COLORADO SPRINGS
Mailing Address - State:CO
Mailing Address - Zip Code:80921-7200
Mailing Address - Country:US
Mailing Address - Phone:719-313-8689
Mailing Address - Fax:937-465-9945
Practice Address - Street 1:1840 WOODMOOR DR STE 102
Practice Address - Street 2:
Practice Address - City:MONUMENT
Practice Address - State:CO
Practice Address - Zip Code:80132-9083
Practice Address - Country:US
Practice Address - Phone:719-622-6522
Practice Address - Fax:719-622-6520
Is Sole Proprietor?:No
Enumeration Date:2005-07-15
Last Update Date:2024-07-30
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CODR.0057733207Q00000X
CO0057733207QA0401X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207QA0401XAllopathic & Osteopathic PhysiciansFamily MedicineAddiction Medicine
No207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
TX153159201Medicaid
TX00513TMedicare ID - Type Unspecified
H34931Medicare UPIN