Provider Demographics
NPI:1073008058
Name:NGUYEN, RYAN (OD)
Entity Type:Individual
Prefix:DR
First Name:RYAN
Middle Name:
Last Name:NGUYEN
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 1:5222 N CLARK ST
Mailing Address - Street 2:
Mailing Address - City:CHICAGO
Mailing Address - State:IL
Mailing Address - Zip Code:60640-2377
Mailing Address - Country:US
Mailing Address - Phone:773-275-2538
Mailing Address - Fax:
Practice Address - Street 1:5222 N CLARK ST
Practice Address - Street 2:
Practice Address - City:CHICAGO
Practice Address - State:IL
Practice Address - Zip Code:60640-2377
Practice Address - Country:US
Practice Address - Phone:773-275-2538
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2018-06-22
Last Update Date:2019-08-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLOFC87152W00000X
NYTUV008816152W00000X
CAOPT34192152W00000X
IL046.011354152WC0802X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes152WC0802XEye and Vision Services ProvidersOptometristCorneal and Contact ManagementGroup - Single Specialty
No152W00000XEye and Vision Services ProvidersOptometristGroup - Multi-Specialty