Provider Demographics
NPI:1154435162
Name:RYAN, CARL JOHN (OD)
Entity type:Individual
Prefix:DR
First Name:CARL
Middle Name:JOHN
Last Name:RYAN
Suffix:
Gender:M
Credentials:OD
Other - Prefix:
Other - First Name:
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Other - Last Name:
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Other - Credentials:
Mailing Address - Street 1:901 NW CARLON AVE
Mailing Address - Street 2:SUITE 2
Mailing Address - City:BEND
Mailing Address - State:OR
Mailing Address - Zip Code:97701-2636
Mailing Address - Country:US
Mailing Address - Phone:541-382-3242
Mailing Address - Fax:541-317-3579
Practice Address - Street 1:901 NW CARLON AVE
Practice Address - Street 2:SUITE 2
Practice Address - City:BEND
Practice Address - State:OR
Practice Address - Zip Code:97703-2636
Practice Address - Country:US
Practice Address - Phone:541-382-3242
Practice Address - Fax:541-317-3579
Is Sole Proprietor?:Yes
Enumeration Date:2006-08-18
Last Update Date:2015-07-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OR1944T152W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes152W00000XEye and Vision Services ProvidersOptometrist
Provider Identifiers
StateIdentifier IDID TypeIssuer
ORU22153Medicare UPIN
OR1021330001Medicare NSC
ORR0000PHFTHMedicare PIN