Provider Demographics
NPI:1336646405
Name:WALCZAK, RYAN JAMES (MD)
Entity Type:Individual
Prefix:
First Name:RYAN
Middle Name:JAMES
Last Name:WALCZAK
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:PO BOX 6069
Mailing Address - Street 2:
Mailing Address - City:WEST COLUMBIA
Mailing Address - State:SC
Mailing Address - Zip Code:29171-6069
Mailing Address - Country:US
Mailing Address - Phone:803-936-7530
Mailing Address - Fax:
Practice Address - Street 1:146 E HOSPITAL DR, STE 200
Practice Address - Street 2:
Practice Address - City:WEST COLUMBIA
Practice Address - State:SC
Practice Address - Zip Code:29169-2306
Practice Address - Country:US
Practice Address - Phone:803-936-7530
Practice Address - Fax:803-936-7532
Is Sole Proprietor?:Yes
Enumeration Date:2018-04-06
Last Update Date:2024-01-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
390200000X
SC90440207Y00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Y00000XAllopathic & Osteopathic PhysiciansOtolaryngology
No390200000XStudent, Health CareStudent in an Organized Health Care Education/Training Program