=====================================================
General NPI Number Information
=====================================================
NPI Number | 1417168311
-----------------------------------------------------
Entity Type | Individual
-----------------------------------------------------
Provider Name | ROY LEE JOHNSON III M.D.
-----------------------------------------------------
Gender | Male
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 05/24/2007
-----------------------------------------------------
Last Update Date | 05/05/2020
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 4881 SUGAR MAPLE DR
-----------------------------------------------------
City | WRIGHT PATTERSON AFB
-----------------------------------------------------
State | OH
-----------------------------------------------------
Zip | 45433
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 937-257-0770
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 3131 NEWMARK DR STE 220
-----------------------------------------------------
City | MIAMISBURG
-----------------------------------------------------
State | OH
-----------------------------------------------------
Zip | 45342-5400
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 937-438-8910
-----------------------------------------------------
Fax | 937-436-4984
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position |
-----------------------------------------------------
Name |
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone |
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 207P00000X
-----------------------------------------------------
Taxonomy Name | Emergency Medicine Physician
-----------------------------------------------------
License Number | 35.094004
-----------------------------------------------------
License Number State | OH
-----------------------------------------------------