Provider Demographics
NPI:1073581401
Name:RYAN, CRAIG (DO)
Entity Type:Individual
Prefix:
First Name:CRAIG
Middle Name:
Last Name:RYAN
Suffix:
Gender:M
Credentials:DO
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
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Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:263 FARMINGTON AVE
Mailing Address - Street 2:PROVIDER ENROLLMENT
Mailing Address - City:FARMINGTON
Mailing Address - State:CT
Mailing Address - Zip Code:06030-2212
Mailing Address - Country:US
Mailing Address - Phone:860-679-7503
Mailing Address - Fax:860-679-1610
Practice Address - Street 1:1 ROYCE CIR
Practice Address - Street 2:SUITE 104
Practice Address - City:STORRS MANSFIELD
Practice Address - State:CT
Practice Address - Zip Code:06268-2260
Practice Address - Country:US
Practice Address - Phone:860-487-9200
Practice Address - Fax:860-487-9222
Is Sole Proprietor?:No
Enumeration Date:2006-03-10
Last Update Date:2023-01-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CT000311207P00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207P00000XAllopathic & Osteopathic PhysiciansEmergency Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
CT1073581401Medicaid
CT000311OtherCT LIC #