Provider Demographics
NPI:1295759439
Name:RYAN, TIMOTHY MATTHEW (MD)
Entity type:Individual
Prefix:
First Name:TIMOTHY
Middle Name:MATTHEW
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 1:225 S LAKE AVE
Mailing Address - Street 2:535
Mailing Address - City:PASADENA
Mailing Address - State:CA
Mailing Address - Zip Code:91101-3005
Mailing Address - Country:US
Mailing Address - Phone:626-795-6596
Mailing Address - Fax:626-795-8247
Practice Address - Street 1:1420 S CENTRAL AVE
Practice Address - Street 2:
Practice Address - City:GLENDALE
Practice Address - State:CA
Practice Address - Zip Code:91204-2508
Practice Address - Country:US
Practice Address - Phone:818-502-2252
Practice Address - Fax:818-502-2317
Is Sole Proprietor?:Yes
Enumeration Date:2006-07-27
Last Update Date:2008-12-04
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAA72433207L00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207L00000XAllopathic & Osteopathic PhysiciansAnesthesiology
Provider Identifiers
StateIdentifier IDID TypeIssuer
CA00A724330OtherBLUE SHIELD
CA00A724330Medicaid
CAWA72433DMedicare PIN
CA00A724330OtherBLUE SHIELD
CAWA72433CMedicare ID - Type Unspecified
CA00A724330Medicaid