Provider Demographics
NPI:1811463300
Name:JOHNSON, NICHOLAS RYAN (OD)
Entity type:Individual
Prefix:DR
First Name:NICHOLAS
Middle Name:RYAN
Last Name:JOHNSON
Suffix:
Gender:M
Credentials:OD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2094 ALBANY POST RD.
Mailing Address - Street 2:
Mailing Address - City:MONTROSE
Mailing Address - State:NY
Mailing Address - Zip Code:10548
Mailing Address - Country:US
Mailing Address - Phone:813-361-3777
Mailing Address - Fax:
Practice Address - Street 1:2094 ALBANY POST RD.
Practice Address - Street 2:
Practice Address - City:MONTROSE
Practice Address - State:NY
Practice Address - Zip Code:10548
Practice Address - Country:US
Practice Address - Phone:813-361-3777
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2018-10-23
Last Update Date:2018-10-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY8855152W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes152W00000XEye and Vision Services ProvidersOptometrist