Provider Demographics
NPI:1891748984
Name:RYAN, REBECCA D (OD)
Entity Type:Individual
Prefix:DR
First Name:REBECCA
Middle Name:D
Last Name:RYAN
Suffix:
Gender:F
Credentials:OD
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Mailing Address - Street 1:8309 N KNOXVILLE AVE
Mailing Address - Street 2:
Mailing Address - City:PEORIA
Mailing Address - State:IL
Mailing Address - Zip Code:61615-2170
Mailing Address - Country:US
Mailing Address - Phone:309-693-9540
Mailing Address - Fax:309-693-9754
Practice Address - Street 1:901 W MORTON AVE
Practice Address - Street 2:STE. 113
Practice Address - City:JACKSONVILLE
Practice Address - State:IL
Practice Address - Zip Code:62650-3145
Practice Address - Country:US
Practice Address - Phone:217-243-6506
Practice Address - Fax:217-243-4902
Is Sole Proprietor?:No
Enumeration Date:2006-05-18
Last Update Date:2015-10-23
Deactivation Date:
Deactivation Code:
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Provider Licenses
StateLicense IDTaxonomies
IL046008280152W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes152W00000XEye and Vision Services ProvidersOptometrist
Provider Identifiers
StateIdentifier IDID TypeIssuer
ILU26503Medicare UPIN