Provider Demographics
NPI:1891752812
Name:ANDERSON, RYAN B (MD)
Entity Type:Individual
Prefix:DR
First Name:RYAN
Middle Name:B
Last Name:ANDERSON
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 1:2030 S SOLANO DR
Mailing Address - Street 2:
Mailing Address - City:LAS CRUCES
Mailing Address - State:NM
Mailing Address - Zip Code:88001-5402
Mailing Address - Country:US
Mailing Address - Phone:575-521-1158
Mailing Address - Fax:575-521-1007
Practice Address - Street 1:2030 S SOLANO DR
Practice Address - Street 2:
Practice Address - City:LAS CRUCES
Practice Address - State:NM
Practice Address - Zip Code:88001-5402
Practice Address - Country:US
Practice Address - Phone:575-521-1158
Practice Address - Fax:575-521-1007
Is Sole Proprietor?:Yes
Enumeration Date:2006-04-26
Last Update Date:2012-05-04
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AZ35249207W00000X
NMMD2005-0470207W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207W00000XAllopathic & Osteopathic PhysiciansOphthalmology
Provider Identifiers
StateIdentifier IDID TypeIssuer
AZZ111923Medicare PIN
AZZ111924Medicare PIN
AZZ111922Medicare PIN
AZZ111920Medicare PIN
AZZ111921Medicare PIN
UTI36974Medicare UPIN