Provider Demographics
NPI:1295028058
Name:HEADY, RYAN JEFFREY (OD)
Entity type:Individual
Prefix:DR
First Name:RYAN
Middle Name:JEFFREY
Last Name:HEADY
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 1:1229 E SEMINOLE ST STE 430
Mailing Address - Street 2:
Mailing Address - City:SPRINGFIELD
Mailing Address - State:MO
Mailing Address - Zip Code:65804-2227
Mailing Address - Country:US
Mailing Address - Phone:417-820-9393
Mailing Address - Fax:260-569-0760
Practice Address - Street 1:1229 E SEMINOLE ST STE 430
Practice Address - Street 2:
Practice Address - City:SPRINGFIELD
Practice Address - State:MO
Practice Address - Zip Code:65804-2227
Practice Address - Country:US
Practice Address - Phone:417-820-9393
Practice Address - Fax:260-569-0760
Is Sole Proprietor?:No
Enumeration Date:2011-05-25
Last Update Date:2018-09-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IN18003832152W00000X
MO2013000334152W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes152W00000XEye and Vision Services ProvidersOptometrist
Provider Identifiers
StateIdentifier IDID TypeIssuer
IN201214370Medicaid
IN452570034Medicare PIN
IN160450042Medicare PIN