Healthcare Provider Details

I. General information

NPI: 1184653404
Provider Name (Legal Business Name): RYAN SCOTT JOHNSON O.D.
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 06/30/2006
Last Update Date: 07/19/2021
Certification Date: 07/19/2021
Deactivation Date:
Reactivation Date:

III. Provider practice location address

4240 YELLOWSTONE AVE
CHUBBUCK ID
83202-2420
US

IV. Provider business mailing address

12482 DALLIN RD
POCATELLO ID
83202-5073
US

V. Phone/Fax

Practice location:
  • Phone: 208-238-2020
  • Fax: 208-238-2069
Mailing address:
  • Phone: 208-241-9145
  • Fax: 208-238-2069

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code152W00000X
TaxonomyOptometrist
License NumberODP-1037
License Number StateID

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: