Provider Demographics
NPI:1760555130
Name:ALDRICH, RYAN KYLE (MD)
Entity Type:Individual
Prefix:
First Name:RYAN
Middle Name:KYLE
Last Name:ALDRICH
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 1:3204 MEDICAL PARK DR
Mailing Address - Street 2:
Mailing Address - City:SHAWNEE
Mailing Address - State:OK
Mailing Address - Zip Code:74804-5014
Mailing Address - Country:US
Mailing Address - Phone:405-878-6800
Mailing Address - Fax:405-878-6831
Practice Address - Street 1:3204 MEDICAL PARK DR
Practice Address - Street 2:
Practice Address - City:SHAWNEE
Practice Address - State:OK
Practice Address - Zip Code:74804-5014
Practice Address - Country:US
Practice Address - Phone:405-878-6800
Practice Address - Fax:405-878-6831
Is Sole Proprietor?:No
Enumeration Date:2006-11-15
Last Update Date:2010-03-25
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OK24496207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
OK400647OtherRAILROAD RETIREMENT TRUST (RR MEDICARE)
OK200100900AMedicaid
OK400647OtherRAILROAD RETIREMENT TRUST (RR MEDICARE)