MEDICARE: DR. RYAN WESLEY JOHNSON D.O.

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	207P00000X	Emergency Medicine Physician	DO.000283	LA
2	207P00000X	Emergency Medicine Physician	OS 12318	FL

General Provider Information

NPI Number	:	1699091066
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	DR. RYAN WESLEY JOHNSON D.O.

Provider Business Mailing Address
First Line	:	2995 CRYSTAL BEACH RD
Second Line	:
City	:	WINTER HAVEN
State	:	FL
Zip	:	33880-4914
Country	:	US
Telephone Number	:	863-585-4591
Fax Number	:

Provider Business Practice Location Address
First Line	:	2995 CRYSTAL BEACH RD
Second Line	:
City	:	WINTER HAVEN
State	:	FL
Zip	:	33880-4914
Country	:	US
Telephone Number	:	863-585-4591
Fax Number	:

Authorized Official
Title or Position	:
Name	:
Credential	:
Telephone Number	:

Provider Enumeration Date	:	04/10/2010
Last Update Date	:	08/19/2013

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