Healthcare Provider Details

I. General information

NPI: 1588242010
Provider Name (Legal Business Name): RYAN MONTGOMERY JOHNSON
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 03/29/2021
Last Update Date: 06/04/2026
Certification Date: 06/04/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

640 S STATE ST
DOVER DE
19901-3530
US

IV. Provider business mailing address

640 S STATE ST # MC3055
DOVER DE
19901-3530
US

V. Phone/Fax

Practice location:
  • Phone: 302-674-4700
  • Fax: 302-744-6215
Mailing address:
  • Phone: 302-674-4700
  • Fax: 302-744-6215

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code2085R0202X
TaxonomyDiagnostic Radiology Physician
License NumberC2-0024325
License Number StateDE

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: