Provider Demographics
NPI:1497872576
Name:DVORAK, RYAN ALLEN (MD)
Entity Type:Individual
Prefix:DR
First Name:RYAN
Middle Name:ALLEN
Last Name:DVORAK
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 1:7701 PACIFIC ST
Mailing Address - Street 2:SUITE 117
Mailing Address - City:OMAHA
Mailing Address - State:NE
Mailing Address - Zip Code:68114-5480
Mailing Address - Country:US
Mailing Address - Phone:402-238-1539
Mailing Address - Fax:402-397-5265
Practice Address - Street 1:8303 DODGE ST
Practice Address - Street 2:
Practice Address - City:OMAHA
Practice Address - State:NE
Practice Address - Zip Code:68114-4108
Practice Address - Country:US
Practice Address - Phone:402-354-4344
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2007-03-23
Last Update Date:2011-09-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI4301085342390200000X
NE261712085R0202X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2085R0202XAllopathic & Osteopathic PhysiciansRadiologyDiagnostic Radiology
No390200000XStudent, Health CareStudent in an Organized Health Care Education/Training Program
Provider Identifiers
StateIdentifier IDID TypeIssuer
NE47052676314Medicaid
MO1497872576Medicaid
IA1497872576Medicaid
NE092284004Medicare PIN