Provider Demographics
NPI:1801981030
Name:ELLWEIN, RYAN (OD)
Entity type:Individual
Prefix:DR
First Name:RYAN
Middle Name:
Last Name:ELLWEIN
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 1:3501 W 41ST ST
Mailing Address - Street 2:SUITE 110B
Mailing Address - City:SIOUX FALLS
Mailing Address - State:SD
Mailing Address - Zip Code:57106-0709
Mailing Address - Country:US
Mailing Address - Phone:605-271-9060
Mailing Address - Fax:605-271-9062
Practice Address - Street 1:3501 W 41ST ST
Practice Address - Street 2:SUITE 110B
Practice Address - City:SIOUX FALLS
Practice Address - State:SD
Practice Address - Zip Code:57106-0709
Practice Address - Country:US
Practice Address - Phone:605-271-9060
Practice Address - Fax:605-271-9062
Is Sole Proprietor?:Yes
Enumeration Date:2006-10-04
Last Update Date:2008-03-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
SD595152W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes152W00000XEye and Vision Services ProvidersOptometrist
Provider Identifiers
StateIdentifier IDID TypeIssuer
SD9203364Medicaid
SD9203364Medicaid