Provider Demographics
NPI:1659446037
Name:JOHNSON, ROYAL GARY (MD)
Entity type:Individual
Prefix:DR
First Name:ROYAL
Middle Name:GARY
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:PO BOX 2153 DEPT 40339
Mailing Address - Street 2:
Mailing Address - City:BIRMINGHAM
Mailing Address - State:AL
Mailing Address - Zip Code:35287-9387
Mailing Address - Country:US
Mailing Address - Phone:423-310-1642
Mailing Address - Fax:706-270-0487
Practice Address - Street 1:944 W KAWAILANI ST
Practice Address - Street 2:
Practice Address - City:HILO
Practice Address - State:HI
Practice Address - Zip Code:96720-3218
Practice Address - Country:US
Practice Address - Phone:808-959-9151
Practice Address - Fax:808-522-4345
Is Sole Proprietor?:No
Enumeration Date:2006-11-21
Last Update Date:2022-12-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
HIMD-6183207RG0300X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207RG0300XAllopathic & Osteopathic PhysiciansInternal MedicineGeriatric Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
HI059564 01Medicaid
HI6963444OtherUHA
HI0000079020OtherHMSA
HI6963444OtherUHA
HIE57489Medicare UPIN