Provider Demographics
NPI:1205919909
Name:RYAN, JOHN JOSEPH (MD)
Entity type:Individual
Prefix:DR
First Name:JOHN
Middle Name:JOSEPH
Last Name:RYAN
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:PO BOX 600447
Mailing Address - Street 2:
Mailing Address - City:CHARLOTTE
Mailing Address - State:NC
Mailing Address - Zip Code:28260-0447
Mailing Address - Country:US
Mailing Address - Phone:704-316-4930
Mailing Address - Fax:704-316-4931
Practice Address - Street 1:7482 WATERSIDE CROSSING BLVD
Practice Address - Street 2:SUITE 202
Practice Address - City:DENVER
Practice Address - State:NC
Practice Address - Zip Code:28037-3005
Practice Address - Country:US
Practice Address - Phone:704-316-4930
Practice Address - Fax:704-316-4931
Is Sole Proprietor?:No
Enumeration Date:2006-10-24
Last Update Date:2015-03-31
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NC200700782207Q00000X
OH35.047427207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
OH0500603Medicaid
NC5908251Medicaid
OHA15264Medicare UPIN
NC2075260Medicare PIN
OHRY0521324Medicare ID - Type Unspecified