Provider Demographics
NPI:1851398630
Name:RYAN, ROBERT A (OD)
Entity Type:Individual
Prefix:
First Name:ROBERT
Middle Name:A
Last Name:RYAN
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 1:169 RUE DE VL
Mailing Address - Street 2:
Mailing Address - City:ROCHESTER
Mailing Address - State:NY
Mailing Address - Zip Code:14618-5619
Mailing Address - Country:US
Mailing Address - Phone:585-271-2990
Mailing Address - Fax:585-271-6321
Practice Address - Street 1:169 RUE DE VL
Practice Address - Street 2:
Practice Address - City:ROCHESTER
Practice Address - State:NY
Practice Address - Zip Code:14618-5619
Practice Address - Country:US
Practice Address - Phone:585-271-2990
Practice Address - Fax:585-271-6321
Is Sole Proprietor?:No
Enumeration Date:2005-07-07
Last Update Date:2023-07-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY5025152W00000X
NYVUT005025-1152W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes152W00000XEye and Vision Services ProvidersOptometrist
Provider Identifiers
StateIdentifier IDID TypeIssuer
NY01594870Medicaid
NY11372BMedicare ID - Type Unspecified
NY01594870Medicaid