Provider Demographics
NPI:1235457037
Name:TACKLA, RYAN DAVID (MD)
Entity Type:Individual
Prefix:DR
First Name:RYAN
Middle Name:DAVID
Last Name:TACKLA
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
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Other - Credentials:
Mailing Address - Street 1:PO BOX 643398
Mailing Address - Street 2:
Mailing Address - City:CINCINNATI
Mailing Address - State:OH
Mailing Address - Zip Code:45264-3398
Mailing Address - Country:US
Mailing Address - Phone:513-221-1100
Mailing Address - Fax:513-684-4501
Practice Address - Street 1:3825 EDWARDS RD STE 300
Practice Address - Street 2:
Practice Address - City:CINCINNATI
Practice Address - State:OH
Practice Address - Zip Code:45209-1288
Practice Address - Country:US
Practice Address - Phone:513-221-1100
Practice Address - Fax:513-684-4501
Is Sole Proprietor?:Yes
Enumeration Date:2010-05-04
Last Update Date:2020-07-28
Deactivation Date:
Deactivation Code:
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Provider Licenses
StateLicense IDTaxonomies
OH35.122447207T00000X
OK33193193400000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes193400000XGroupSingle Specialty
Yes207T00000XAllopathic & Osteopathic PhysiciansNeurological Surgery