Provider Demographics
NPI:1538650726
Name:CAPOUCH, RYAN (OD)
Entity Type:Individual
Prefix:
First Name:RYAN
Middle Name:
Last Name:CAPOUCH
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 1:5120 PROSPERITY WAY S STE 114
Mailing Address - Street 2:
Mailing Address - City:FARGO
Mailing Address - State:ND
Mailing Address - Zip Code:58104-7568
Mailing Address - Country:US
Mailing Address - Phone:701-404-9096
Mailing Address - Fax:701-436-9223
Practice Address - Street 1:5120 PROSPERITY WAY S STE 114
Practice Address - Street 2:
Practice Address - City:FARGO
Practice Address - State:ND
Practice Address - Zip Code:58104-7568
Practice Address - Country:US
Practice Address - Phone:701-404-9096
Practice Address - Fax:701-436-9223
Is Sole Proprietor?:No
Enumeration Date:2018-05-23
Last Update Date:2021-06-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NDPENDING152W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes152W00000XEye and Vision Services ProvidersOptometrist