Provider Demographics
NPI:1881629871
Name:RYAN, MARK E (MD)
Entity Type:Individual
Prefix:
First Name:MARK
Middle Name:E
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 1:321 FORTUNE BLVD
Mailing Address - Street 2:
Mailing Address - City:MILFORD
Mailing Address - State:MA
Mailing Address - Zip Code:01757-1750
Mailing Address - Country:US
Mailing Address - Phone:508-478-5996
Mailing Address - Fax:
Practice Address - Street 1:HOLLISTON PEDIATRIC GROUP
Practice Address - Street 2:321 FORTUNE BLVD
Practice Address - City:MILFORD
Practice Address - State:MA
Practice Address - Zip Code:01757
Practice Address - Country:US
Practice Address - Phone:508-478-5996
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2006-07-11
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MA70606208000000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208000000XAllopathic & Osteopathic PhysiciansPediatrics