Provider Demographics
NPI:1669487252
Name:COWBURN, RYAN WILLIAM (OD)
Entity Type:Individual
Prefix:DR
First Name:RYAN
Middle Name:WILLIAM
Last Name:COWBURN
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 1:2121 SHELLY DR
Mailing Address - Street 2:
Mailing Address - City:INDIANA
Mailing Address - State:PA
Mailing Address - Zip Code:15701-2395
Mailing Address - Country:US
Mailing Address - Phone:724-349-1237
Mailing Address - Fax:724-465-0127
Practice Address - Street 1:2121 SHELLY DR
Practice Address - Street 2:
Practice Address - City:INDIANA
Practice Address - State:PA
Practice Address - Zip Code:15701-2395
Practice Address - Country:US
Practice Address - Phone:724-349-1237
Practice Address - Fax:724-465-0127
Is Sole Proprietor?:Yes
Enumeration Date:2006-07-30
Last Update Date:2009-07-31
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
PAOEG000276152W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes152W00000XEye and Vision Services ProvidersOptometrist
Provider Identifiers
StateIdentifier IDID TypeIssuer
PA001923214Medicaid
PA060401Medicare ID - Type Unspecified
5172020001Medicare NSC
127923Medicare PIN
PA5172020002Medicare NSC
PA001923214Medicaid