Provider Demographics
NPI:1699091066
Name:JOHNSON, RYAN WESLEY (DO)
Entity type:Individual
Prefix:DR
First Name:RYAN
Middle Name:WESLEY
Last Name:JOHNSON
Suffix:
Gender:M
Credentials:DO
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2995 CRYSTAL BEACH RD
Mailing Address - Street 2:
Mailing Address - City:WINTER HAVEN
Mailing Address - State:FL
Mailing Address - Zip Code:33880-4914
Mailing Address - Country:US
Mailing Address - Phone:863-585-4591
Mailing Address - Fax:
Practice Address - Street 1:2995 CRYSTAL BEACH RD
Practice Address - Street 2:
Practice Address - City:WINTER HAVEN
Practice Address - State:FL
Practice Address - Zip Code:33880-4914
Practice Address - Country:US
Practice Address - Phone:863-585-4591
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2010-04-10
Last Update Date:2013-08-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
LADO.000283207P00000X
FLOS 12318207P00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207P00000XAllopathic & Osteopathic PhysiciansEmergency Medicine