Provider Demographics
NPI:1518167147
Name:RUIZ, IVAN (ORTHOTIST)
Entity type:Individual
Prefix:MR
First Name:IVAN
Middle Name:
Last Name:RUIZ
Suffix:
Gender:M
Credentials:ORTHOTIST
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:12460 CRABAPPLE RD
Mailing Address - Street 2:SUITE 202-336
Mailing Address - City:ALPHARETTA
Mailing Address - State:GA
Mailing Address - Zip Code:30004-6602
Mailing Address - Country:US
Mailing Address - Phone:404-833-8737
Mailing Address - Fax:770-751-0961
Practice Address - Street 1:9690 VANTANA WAY
Practice Address - Street 2:
Practice Address - City:JOHNS CREEK
Practice Address - State:GA
Practice Address - Zip Code:30022-6394
Practice Address - Country:US
Practice Address - Phone:404-833-8737
Practice Address - Fax:770-751-0961
Is Sole Proprietor?:No
Enumeration Date:2007-07-22
Last Update Date:2007-10-31
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GA51222Z00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes222Z00000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersOrthotist