Provider Demographics
NPI:1639593908
Name:EDWARDS, RYAN (OD)
Entity Type:Individual
Prefix:DR
First Name:RYAN
Middle Name:
Last Name:EDWARDS
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 1:3965 75TH ST # 105
Mailing Address - Street 2:
Mailing Address - City:AURORA
Mailing Address - State:IL
Mailing Address - Zip Code:60504-7925
Mailing Address - Country:US
Mailing Address - Phone:815-260-6884
Mailing Address - Fax:
Practice Address - Street 1:3965 75TH ST # 105
Practice Address - Street 2:
Practice Address - City:AURORA
Practice Address - State:IL
Practice Address - Zip Code:60504-7925
Practice Address - Country:US
Practice Address - Phone:815-260-6884
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2014-02-07
Last Update Date:2021-03-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI4901004791152W00000X
IL046010924152WV0400X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes152WV0400XEye and Vision Services ProvidersOptometristVision Therapy
No152W00000XEye and Vision Services ProvidersOptometrist