Provider Demographics
NPI:1528042769
Name:LEBRETON, RYAN MICHAEL (OD)
Entity Type:Individual
Prefix:
First Name:RYAN
Middle Name:MICHAEL
Last Name:LEBRETON
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:PO BOX 883
Mailing Address - Street 2:
Mailing Address - City:THE DALLES
Mailing Address - State:OR
Mailing Address - Zip Code:97058-0883
Mailing Address - Country:US
Mailing Address - Phone:541-296-2911
Mailing Address - Fax:541-296-2224
Practice Address - Street 1:415 WASHINGTON ST
Practice Address - Street 2:
Practice Address - City:THE DALLES
Practice Address - State:OR
Practice Address - Zip Code:97058-2215
Practice Address - Country:US
Practice Address - Phone:541-296-2911
Practice Address - Fax:541-296-2224
Is Sole Proprietor?:No
Enumeration Date:2005-12-01
Last Update Date:2007-11-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OR2973AT152W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes152W00000XEye and Vision Services ProvidersOptometrist
Provider Identifiers
StateIdentifier IDID TypeIssuer
OR233145Medicaid
OR233145Medicaid
R119823Medicare PIN
V00532Medicare UPIN