Provider Demographics
NPI:1538103148
Name:NIELSON, RYAN E (OD)
Entity type:Individual
Prefix:DR
First Name:RYAN
Middle Name:E
Last Name:NIELSON
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 1:2320 E GALA ST
Mailing Address - Street 2:SUITE 400
Mailing Address - City:MERIDIAN
Mailing Address - State:ID
Mailing Address - Zip Code:83642-7091
Mailing Address - Country:US
Mailing Address - Phone:208-898-0304
Mailing Address - Fax:
Practice Address - Street 1:1715 S WELLS AVE
Practice Address - Street 2:
Practice Address - City:MERIDIAN
Practice Address - State:ID
Practice Address - Zip Code:83642-5756
Practice Address - Country:US
Practice Address - Phone:208-898-0304
Practice Address - Fax:208-898-0380
Is Sole Proprietor?:No
Enumeration Date:2006-06-15
Last Update Date:2024-09-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IDODP-100015152W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes152W00000XEye and Vision Services ProvidersOptometrist
Provider Identifiers
StateIdentifier IDID TypeIssuer
ID806418901Medicaid
ID806418900Medicaid
IDV6945OtherBLUE CROSS GROUP #
ID000010139527OtherBLUE SHIELD OF IDAHO
IDV6952OtherBLUE CROSS IDAHO
ID1594248Medicare ID - Type Unspecified
IDV6945OtherBLUE CROSS GROUP #
IDV6952OtherBLUE CROSS IDAHO