Provider Demographics
NPI:1245415454
Name:MIYAMOTO, RYAN KEITH (MD)
Entity Type:Individual
Prefix:DR
First Name:RYAN
Middle Name:KEITH
Last Name:MIYAMOTO
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 1:1717 N E ST
Mailing Address - Street 2:430
Mailing Address - City:PENSACOLA
Mailing Address - State:FL
Mailing Address - Zip Code:32501-6339
Mailing Address - Country:US
Mailing Address - Phone:850-437-8711
Mailing Address - Fax:
Practice Address - Street 1:1717 N E ST
Practice Address - Street 2:430
Practice Address - City:PENSACOLA
Practice Address - State:FL
Practice Address - Zip Code:32501-6339
Practice Address - Country:US
Practice Address - Phone:850-437-8711
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2008-01-07
Last Update Date:2017-02-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI4301097056208800000X
FLME126100208800000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208800000XAllopathic & Osteopathic PhysiciansUrology
Provider Identifiers
StateIdentifier IDID TypeIssuer
FL016158700Medicaid
FLIK737ZMedicare PIN