Provider Demographics
NPI:1548211220
Name:RYAN, MARK G
Entity Type:Individual
Prefix:
First Name:MARK
Middle Name:G
Last Name:RYAN
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:87 GRANDVIEW AVE
Mailing Address - Street 2:
Mailing Address - City:WATERBURY
Mailing Address - State:CT
Mailing Address - Zip Code:06708-2514
Mailing Address - Country:US
Mailing Address - Phone:203-574-2020
Mailing Address - Fax:203-596-2230
Practice Address - Street 1:1457 WHALLEY AVE
Practice Address - Street 2:
Practice Address - City:NEW HAVEN
Practice Address - State:CT
Practice Address - Zip Code:06515-1153
Practice Address - Country:US
Practice Address - Phone:203-562-3937
Practice Address - Fax:203-389-3994
Is Sole Proprietor?:Not Answered
Enumeration Date:2006-05-15
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CT002155152W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes152W00000XEye and Vision Services ProvidersOptometrist
Provider Identifiers
StateIdentifier IDID TypeIssuer
T22971Medicare UPIN