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General NPI Number Information
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NPI Number | 1366706525
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Entity Type | Individual
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Provider Name | RYAN JOHNSON O.D
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Gender | Male
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Dates
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Enumeration Date | 07/02/2012
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Last Update Date | 07/23/2015
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Provider Practice Location Address
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Address Line | 7960 W RIFLEMAN ST SUITE 150
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City | BOISE
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State | ID
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Zip | 83704-9064
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Country | US
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Telephone | 208-377-8899
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Fax |
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Provider Business Mailing Address
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Address Line | 7960 W RIFLEMAN ST SUITE 150
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City | BOISE
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State | ID
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Zip | 83704-9064
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Country | US
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Telephone | 208-377-8899
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Fax |
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Authorized Official
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Title or Position |
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Name |
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Credential |
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Telephone |
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 152W00000X
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Taxonomy Name | Optometrist
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License Number | 14467
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License Number State | CA
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Taxonomy #2
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Taxonomy Code | 152WV0400X
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Taxonomy Name | Vision Therapy Optometrist
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License Number | ODP-100269
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License Number State | ID
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