Provider Demographics
NPI:1285610253
Name:JOHNSON, ROBERT RILEY (MD)
Entity type:Individual
Prefix:
First Name:ROBERT
Middle Name:RILEY
Last Name:JOHNSON
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:3 RIVERSIDE CIRCLE
Mailing Address - Street 2:
Mailing Address - City:ROANOKE
Mailing Address - State:VA
Mailing Address - Zip Code:24016
Mailing Address - Country:US
Mailing Address - Phone:540-224-5170
Mailing Address - Fax:540-983-8229
Practice Address - Street 1:3 RIVERSIDE CIRCLE
Practice Address - Street 2:302
Practice Address - City:ROANOKE
Practice Address - State:VA
Practice Address - Zip Code:24016
Practice Address - Country:US
Practice Address - Phone:540-224-5170
Practice Address - Fax:540-983-8229
Is Sole Proprietor?:No
Enumeration Date:2005-12-21
Last Update Date:2011-08-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
VA0101041298207RR0500X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207RR0500XAllopathic & Osteopathic PhysiciansInternal MedicineRheumatology
Provider Identifiers
StateIdentifier IDID TypeIssuer
VA5887046Medicaid
VA5859191Medicaid
VA110226922Medicare PIN
VA000865C19Medicare PIN
110008213Medicare PIN
VA5859191Medicaid