Healthcare Provider Details

I. General information

NPI: 1851970693
Provider Name (Legal Business Name): RYAN MATTHEW JOHNSON MD
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 04/07/2021
Last Update Date: 08/28/2026
Certification Date: 08/28/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2160 S 1ST AVE
MAYWOOD IL
60153-3328
US

IV. Provider business mailing address

2160 S 1ST AVE
MAYWOOD IL
60153-3328
US

V. Phone/Fax

Practice location:
  • Phone: 804-304-8541
  • Fax:
Mailing address:
  • Phone: 804-304-8541
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code208600000X
TaxonomySurgery Physician
License Number036165617
License Number StateIL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: