Provider Demographics
NPI:1205042975
Name:RYAN, CLODAGH THERESE (MD)
Entity Type:Individual
Prefix:DR
First Name:CLODAGH
Middle Name:THERESE
Last Name:RYAN
Suffix:
Gender:F
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1400 W 47TH ST STE 1
Mailing Address - Street 2:
Mailing Address - City:LA GRANGE
Mailing Address - State:IL
Mailing Address - Zip Code:60525-6148
Mailing Address - Country:US
Mailing Address - Phone:708-571-2272
Mailing Address - Fax:281-667-0104
Practice Address - Street 1:1400 W 47TH ST STE 1
Practice Address - Street 2:
Practice Address - City:LA GRANGE
Practice Address - State:IL
Practice Address - Zip Code:60525-6148
Practice Address - Country:US
Practice Address - Phone:708-571-2272
Practice Address - Fax:281-667-0104
Is Sole Proprietor?:Yes
Enumeration Date:2007-05-16
Last Update Date:2020-02-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL036120989207Q00000X
IL125049455390200000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
No390200000XStudent, Health CareStudent in an Organized Health Care Education/Training Program