Provider Demographics
NPI:1821101635
Name:O'CONNOR, RYAN S (MD)
Entity Type:Individual
Prefix:
First Name:RYAN
Middle Name:S
Last Name:O'CONNOR
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 1:190 PORTOLA RD
Mailing Address - Street 2:
Mailing Address - City:PORTOLA VALLEY
Mailing Address - State:CA
Mailing Address - Zip Code:94028-7852
Mailing Address - Country:US
Mailing Address - Phone:310-990-9979
Mailing Address - Fax:650-851-4675
Practice Address - Street 1:1442 KELLAM AVE
Practice Address - Street 2:
Practice Address - City:LOS ANGELES
Practice Address - State:CA
Practice Address - Zip Code:90026-5138
Practice Address - Country:US
Practice Address - Phone:310-990-9979
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2006-08-16
Last Update Date:2011-09-26
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAA95130207P00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207P00000XAllopathic & Osteopathic PhysiciansEmergency Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
CA00A951300Medicaid
CA00A951300Medicaid