Provider Demographics
NPI:1750643235
Name:OUILLETTE, RYAN MATTHEW (MD)
Entity Type:Individual
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First Name:RYAN
Middle Name:MATTHEW
Last Name:OUILLETTE
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Gender:M
Credentials:MD
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Mailing Address - Street 1:23550 PARK ST
Mailing Address - Street 2:STE 100
Mailing Address - City:DEARBORN
Mailing Address - State:MI
Mailing Address - Zip Code:48124-2592
Mailing Address - Country:US
Mailing Address - Phone:313-730-0500
Mailing Address - Fax:313-730-0606
Practice Address - Street 1:23550 PARK ST
Practice Address - Street 2:STE 100
Practice Address - City:DEARBORN
Practice Address - State:MI
Practice Address - Zip Code:48124-2592
Practice Address - Country:US
Practice Address - Phone:313-730-0500
Practice Address - Fax:313-730-0606
Is Sole Proprietor?:No
Enumeration Date:2012-06-12
Last Update Date:2019-02-18
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Provider Licenses
StateLicense IDTaxonomies
MI4301111844207XX0005X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207XX0005XAllopathic & Osteopathic PhysiciansOrthopaedic SurgerySports Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
MI4301111844OtherMICHIGAN BUREAU OF PROFESSIONAL LICENSING