Provider Demographics
NPI:1639552169
Name:WIDDISON, RYAN (OD)
Entity Type:Individual
Prefix:
First Name:RYAN
Middle Name:
Last Name:WIDDISON
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 1:1925 FLORENCE AVE
Mailing Address - Street 2:
Mailing Address - City:KINGMAN
Mailing Address - State:AZ
Mailing Address - Zip Code:86401-4617
Mailing Address - Country:US
Mailing Address - Phone:928-753-2106
Mailing Address - Fax:928-753-4283
Practice Address - Street 1:1925 FLORENCE AVE
Practice Address - Street 2:
Practice Address - City:KINGMAN
Practice Address - State:AZ
Practice Address - Zip Code:86401-4617
Practice Address - Country:US
Practice Address - Phone:928-753-2106
Practice Address - Fax:928-753-4283
Is Sole Proprietor?:No
Enumeration Date:2015-07-01
Last Update Date:2015-07-01
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AZ2066152W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes152W00000XEye and Vision Services ProvidersOptometrist