Provider Demographics
NPI:1275507055
Name:RYAN, THOMAS P (DO)
Entity Type:Individual
Prefix:
First Name:THOMAS
Middle Name:P
Last Name:RYAN
Suffix:
Gender:M
Credentials:DO
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2622 LAKE AVE
Mailing Address - Street 2:
Mailing Address - City:FORT WAYNE
Mailing Address - State:IN
Mailing Address - Zip Code:46805-5410
Mailing Address - Country:US
Mailing Address - Phone:260-425-3100
Mailing Address - Fax:260-425-3604
Practice Address - Street 1:2622 LAKE AVE
Practice Address - Street 2:
Practice Address - City:FORT WAYNE
Practice Address - State:IN
Practice Address - Zip Code:46805-5410
Practice Address - Country:US
Practice Address - Phone:260-425-3100
Practice Address - Fax:260-425-3604
Is Sole Proprietor?:No
Enumeration Date:2006-02-16
Last Update Date:2015-03-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IN02001220A207RC0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207RC0000XAllopathic & Osteopathic PhysiciansInternal MedicineCardiovascular Disease
Provider Identifiers
StateIdentifier IDID TypeIssuer
IN100330950Medicaid
INE21659Medicare UPIN
IN100330950Medicaid
IN100330950Medicaid