Healthcare Provider Details

I. General information

NPI: 1306820915
Provider Name (Legal Business Name): RONALD STUART JOHNSON PH.D.
Entity Type: Individual
Gender: Male
Sole Proprietor: X

II. Dates (important events)

Enumeration Date: 12/06/2005
Last Update Date: 07/08/2007
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

320 YOUNG RD 71 MDOS/SGOML BUILDING 248
ENID OK
73705-5506
US

IV. Provider business mailing address

3702 WILLOW LAKE LN
ENID OK
73703-1417
US

V. Phone/Fax

Practice location:
  • Phone: 580-213-7419
  • Fax: 580-213-6423
Mailing address:
  • Phone: 580-234-8817
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code103TC0700X
TaxonomyClinical Psychologist
License Number635
License Number StateNM

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: