Provider Demographics
NPI:1467580308
Name:HARGREAVES, RYAN (OD)
Entity Type:Individual
Prefix:DR
First Name:RYAN
Middle Name:
Last Name:HARGREAVES
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 1:3339 SHERIDAN ST
Mailing Address - Street 2:
Mailing Address - City:HOLLYWOOD
Mailing Address - State:FL
Mailing Address - Zip Code:33021-3606
Mailing Address - Country:US
Mailing Address - Phone:954-962-6627
Mailing Address - Fax:954-962-0910
Practice Address - Street 1:1935 E HALLANDALE BEACH BLVD
Practice Address - Street 2:
Practice Address - City:HALLANDALE BEACH
Practice Address - State:FL
Practice Address - Zip Code:33009-4708
Practice Address - Country:US
Practice Address - Phone:954-458-2112
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2007-03-01
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLOPC3119152W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes152W00000XEye and Vision Services ProvidersOptometrist
Provider Identifiers
StateIdentifier IDID TypeIssuer
FL20800Medicare ID - Type Unspecified
FLU69893Medicare UPIN