Basic Information
| Provider Information | |||||||||
| NPI: | 1417168311 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | JOHNSON | ||||||||
| FirstName: | ROY | ||||||||
| MiddleName: | LEE | ||||||||
| NamePrefix: | DR. | ||||||||
| NameSuffix: | III | ||||||||
| Credential: | M.D. | ||||||||
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| Mailing Information | |||||||||
| Address1: | 3131 NEWMARK DR STE 220 | ||||||||
| Address2: | |||||||||
| City: | MIAMISBURG | ||||||||
| State: | OH | ||||||||
| PostalCode: | 453425400 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 9374388910 | ||||||||
| FaxNumber: | 9374364984 | ||||||||
| Practice Location | |||||||||
| Address1: | 4881 SUGAR MAPLE DR | ||||||||
| Address2: | |||||||||
| City: | WRIGHT PATTERSON AFB | ||||||||
| State: | OH | ||||||||
| PostalCode: | 45433 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 9372570770 | ||||||||
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| Other Information | |||||||||
| ProviderEnumerationDate: | 05/24/2007 | ||||||||
| LastUpdateDate: | 05/05/2020 | ||||||||
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| ProviderGenderCode: | M | ||||||||
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| IsSoleProprietor: | N | ||||||||
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| NPICertificationDate: | 05/05/2020 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 207P00000X | 35.094004 | OH | Y | Allopathic & Osteopathic Physicians | Emergency Medicine |
ID Information
| ID | Type | State | Issuer | Description | 2987111 | 05 | OH | MEDICAID |