Provider Demographics
NPI:1093058687
Name:RYDER, KATIE LYNN (DO)
Entity type:Individual
Prefix:
First Name:KATIE
Middle Name:LYNN
Last Name:RYDER
Suffix:
Gender:F
Credentials:DO
Other - Prefix:
Other - First Name:KATIE
Other - Middle Name:LYNN
Other - Last Name:GROFF
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:DO
Mailing Address - Street 1:PO BOX 2147
Mailing Address - Street 2:
Mailing Address - City:FORT MYERS
Mailing Address - State:FL
Mailing Address - Zip Code:33902-2147
Mailing Address - Country:US
Mailing Address - Phone:239-343-9700
Mailing Address - Fax:239-343-3965
Practice Address - Street 1:8960 COLONIAL CENTER DR STE 302
Practice Address - Street 2:
Practice Address - City:FORT MYERS
Practice Address - State:FL
Practice Address - Zip Code:33905-7810
Practice Address - Country:US
Practice Address - Phone:239-343-9700
Practice Address - Fax:239-343-3965
Is Sole Proprietor?:No
Enumeration Date:2013-04-01
Last Update Date:2024-09-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IDO-1589207RI0011X
FLUO 3999390200000X
FLOS13949207R00000X, 207RC0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207RC0000XAllopathic & Osteopathic PhysiciansInternal MedicineCardiovascular Disease
No207RI0011XAllopathic & Osteopathic PhysiciansInternal MedicineInterventional Cardiology
No390200000XStudent, Health CareStudent in an Organized Health Care Education/Training Program
No207R00000XAllopathic & Osteopathic PhysiciansInternal Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
FL123154100Medicaid