Provider Demographics
NPI:1730150319
Name:RYAN, PETER T (OD)
Entity type:Individual
Prefix:
First Name:PETER
Middle Name:T
Last Name:RYAN
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 1:1111E NORTHERN AVE B
Mailing Address - Street 2:
Mailing Address - City:PHOENIX
Mailing Address - State:AZ
Mailing Address - Zip Code:85020-4188
Mailing Address - Country:US
Mailing Address - Phone:602-242-6888
Mailing Address - Fax:602-242-4654
Practice Address - Street 1:1111E NORTHERN AVE B
Practice Address - Street 2:
Practice Address - City:PHOENIX
Practice Address - State:AZ
Practice Address - Zip Code:85020-4188
Practice Address - Country:US
Practice Address - Phone:602-242-6888
Practice Address - Fax:602-242-4654
Is Sole Proprietor?:Not Answered
Enumeration Date:2006-01-31
Last Update Date:2015-11-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AZ1004152W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes152W00000XEye and Vision Services ProvidersOptometrist
Provider Identifiers
StateIdentifier IDID TypeIssuer
T36668Medicare UPIN