Provider Demographics
NPI:1346981891
Name:SANDBERG, RYAN SCOTT (OD)
Entity Type:Individual
Prefix:
First Name:RYAN
Middle Name:SCOTT
Last Name:SANDBERG
Suffix:
Gender:M
Credentials:OD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:3917 E KESLER LN
Mailing Address - Street 2:
Mailing Address - City:GILBERT
Mailing Address - State:AZ
Mailing Address - Zip Code:85295-2782
Mailing Address - Country:US
Mailing Address - Phone:480-694-4295
Mailing Address - Fax:
Practice Address - Street 1:1240 S SIGNAL BUTTE RD STE 103
Practice Address - Street 2:
Practice Address - City:MESA
Practice Address - State:AZ
Practice Address - Zip Code:85209-1603
Practice Address - Country:US
Practice Address - Phone:480-761-2930
Practice Address - Fax:480-761-2931
Is Sole Proprietor?:No
Enumeration Date:2022-04-06
Last Update Date:2022-10-26
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AZOPT-002632152W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes152W00000XEye and Vision Services ProvidersOptometrist
Provider Identifiers
StateIdentifier IDID TypeIssuer
AZAOtherA