Healthcare Provider Details

I. General information

NPI: 1972181519
Provider Name (Legal Business Name): RYAN JOHNSON DO
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 04/01/2021
Last Update Date: 06/27/2025
Certification Date: 06/27/2025
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2021 PROFESSIONAL CENTER DR STE 100
ORANGE PARK FL
32073-4461
US

IV. Provider business mailing address

2021 PROFESSIONAL CENTER DR STE 100
ORANGE PARK FL
32073-4461
US

V. Phone/Fax

Practice location:
  • Phone: 49-622-9200
  • Fax: 904-622-9188
Mailing address:
  • Phone: 49-622-9200
  • Fax: 904-622-9188

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code390200000X
TaxonomyStudent in an Organized Health Care Education/Training Program
License Number
License Number StateNULL
# 2
Primary TaxonomyN
Taxonomy Code207Q00000X
TaxonomyFamily Medicine Physician
License NumberUO8151
License Number StateFL
# 3
Primary TaxonomyY
Taxonomy Code207R00000X
TaxonomyInternal Medicine Physician
License Number56876
License Number StateFL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: