Healthcare Provider Details

I. General information

NPI: 1114941416
Provider Name (Legal Business Name): RYAN KENJI JOHNSON M.D.
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 07/27/2006
Last Update Date: 02/01/2017
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

5983 E GRANT RD STE 117
TUCSON AZ
85712-2365
US

IV. Provider business mailing address

3200 E CAMELBACK RD STE 250
PHOENIX AZ
85018-2311
US

V. Phone/Fax

Practice location:
  • Phone: 602-933-3166
  • Fax: 602-933-4166
Mailing address:
  • Phone: 602-933-1813
  • Fax: 602-933-1820

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code208000000X
TaxonomyPediatrics Physician
License Number35247
License Number StateAZ
# 2
Primary TaxonomyN
Taxonomy Code208000000X
TaxonomyPediatrics Physician
License Number37244
License Number StateIA
# 3
Primary TaxonomyY
Taxonomy Code2080P0202X
TaxonomyPediatric Cardiology Physician
License Number35247
License Number StateAZ

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: