Provider Demographics
NPI:1710123351
Name:RYAN, MARK LEO (MD)
Entity Type:Individual
Prefix:DR
First Name:MARK
Middle Name:LEO
Last Name:RYAN
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1935 MEDICAL DISTRICT DR # D2000
Mailing Address - Street 2:
Mailing Address - City:DALLAS
Mailing Address - State:TX
Mailing Address - Zip Code:75235-7701
Mailing Address - Country:US
Mailing Address - Phone:214-456-6040
Mailing Address - Fax:214-456-6320
Practice Address - Street 1:1935 MEDICAL DISTRICT DR
Practice Address - Street 2:
Practice Address - City:DALLAS
Practice Address - State:TX
Practice Address - Zip Code:75235
Practice Address - Country:US
Practice Address - Phone:214-456-6040
Practice Address - Fax:214-456-6320
Is Sole Proprietor?:No
Enumeration Date:2009-01-04
Last Update Date:2018-07-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
ARE-97352086S0120X
FLTRN0011332390200000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2086S0120XAllopathic & Osteopathic PhysiciansSurgeryPediatric Surgery
No390200000XStudent, Health CareStudent in an Organized Health Care Education/Training Program