Healthcare Provider Details

I. General information

NPI: 1639863947
Provider Name (Legal Business Name): RYAN JOHNSON DPM
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 06/08/2023
Last Update Date: 06/08/2023
Certification Date: 05/26/2023
Deactivation Date:
Reactivation Date:

III. Provider practice location address

3801 BELLEMEADE AVE STE 110
EVANSVILLE IN
47714-0111
US

IV. Provider business mailing address

1934 SAINT LUCIA DR
NEWBURGH IN
47630-9668
US

V. Phone/Fax

Practice location:
  • Phone: 812-485-8390
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code213ES0103X
TaxonomyFoot & Ankle Surgery Podiatrist
License Number41000465A
License Number StateIN

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: