Provider Demographics
NPI:1164849964
Name:ANDERSON, RYAN (OD)
Entity Type:Individual
Prefix:DR
First Name:RYAN
Middle Name:
Last Name:ANDERSON
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 1:72057 DINAH SHORE DR
Mailing Address - Street 2:SUITE D
Mailing Address - City:RANCHO MIRAGE
Mailing Address - State:CA
Mailing Address - Zip Code:92270-1791
Mailing Address - Country:US
Mailing Address - Phone:760-340-3937
Mailing Address - Fax:760-327-4313
Practice Address - Street 1:555 E TACHEVAH DR
Practice Address - Street 2:SUITE 101E
Practice Address - City:PALM SPRINGS
Practice Address - State:CA
Practice Address - Zip Code:92262-5750
Practice Address - Country:US
Practice Address - Phone:760-327-1561
Practice Address - Fax:760-327-4313
Is Sole Proprietor?:No
Enumeration Date:2014-03-19
Last Update Date:2015-08-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAOPT 15050 TLG152W00000X
CACA15050152W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes152W00000XEye and Vision Services ProvidersOptometrist
Provider Identifiers
StateIdentifier IDID TypeIssuer
CACA156547Medicare PIN
CACA156548Medicare PIN
CACA156546Medicare PIN