Provider Demographics
NPI:1205242500
Name:NICHOLAS, RYAN ALEXANDER (OD)
Entity type:Individual
Prefix:DR
First Name:RYAN
Middle Name:ALEXANDER
Last Name:NICHOLAS
Suffix:
Gender:M
Credentials:OD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2524 SAINT IGNATIUS CT
Mailing Address - Street 2:
Mailing Address - City:ORLANDO
Mailing Address - State:FL
Mailing Address - Zip Code:32835-6500
Mailing Address - Country:US
Mailing Address - Phone:909-542-5208
Mailing Address - Fax:
Practice Address - Street 1:574 N US HIGHWAY 441
Practice Address - Street 2:
Practice Address - City:LADY LAKE
Practice Address - State:FL
Practice Address - Zip Code:32159-3776
Practice Address - Country:US
Practice Address - Phone:352-350-5298
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2014-07-08
Last Update Date:2015-01-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLOPC5007152W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes152W00000XEye and Vision Services ProvidersOptometrist