Provider Demographics
NPI:1164660221
Name:RON RYAN MD PA
Entity Type:Organization
Organization Name:RON RYAN MD PA
Other - Org Name:RONALD CHRISTOPHER RYAN
Other - Org Type:Other Name
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:
Authorized Official - First Name:RONALD
Authorized Official - Middle Name:CHRISTOPHER
Authorized Official - Last Name:RYAN
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:321-383-1332
Mailing Address - Street 1:1917 KNOX MCRAE DR
Mailing Address - Street 2:
Mailing Address - City:TITUSVILLE
Mailing Address - State:FL
Mailing Address - Zip Code:32780-5360
Mailing Address - Country:US
Mailing Address - Phone:321-383-1332
Mailing Address - Fax:321-383-1243
Practice Address - Street 1:1917 KNOX MCRAE DR
Practice Address - Street 2:
Practice Address - City:TITUSVILLE
Practice Address - State:FL
Practice Address - Zip Code:32780-5360
Practice Address - Country:US
Practice Address - Phone:321-383-1332
Practice Address - Fax:321-383-1243
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2009-01-28
Last Update Date:2009-04-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLOPC4171152W00000X
FLME0062417207W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207W00000XAllopathic & Osteopathic PhysiciansOphthalmologyGroup - Multi-Specialty
No152W00000XEye and Vision Services ProvidersOptometristGroup - Multi-Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
FL18692AOther2ND OFFICE LOCATION
FLF25246Medicare UPIN
FLBO084AMedicare PIN
FL18692Medicare PIN
FL18692YMedicare PIN