Provider Demographics
NPI:1164809851
Name:SMITH, RYAN GREGORY (MD)
Entity Type:Individual
Prefix:
First Name:RYAN
Middle Name:GREGORY
Last Name:SMITH
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:555 N 13TH AVE
Mailing Address - Street 2:
Mailing Address - City:UPLAND
Mailing Address - State:CA
Mailing Address - Zip Code:91786-4904
Mailing Address - Country:US
Mailing Address - Phone:909-277-2420
Mailing Address - Fax:909-206-1097
Practice Address - Street 1:555 N 13TH AVE
Practice Address - Street 2:
Practice Address - City:UPLAND
Practice Address - State:CA
Practice Address - Zip Code:91786-4904
Practice Address - Country:US
Practice Address - Phone:909-277-2420
Practice Address - Fax:909-206-1097
Is Sole Proprietor?:Yes
Enumeration Date:2015-05-01
Last Update Date:2023-07-24
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
DEC1-0025611207W00000X
CAA144479207W00000X, 207WX0120X
390200000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207W00000XAllopathic & Osteopathic PhysiciansOphthalmologyGroup - Single Specialty
No207WX0120XAllopathic & Osteopathic PhysiciansOphthalmologyCornea and External Diseases SpecialistGroup - Single Specialty
No390200000XStudent, Health CareStudent in an Organized Health Care Education/Training Program
Provider Identifiers
StateIdentifier IDID TypeIssuer
DEC1-0025611OtherMD LICENSE
CA1164809851OtherNPI