Provider Demographics
NPI:1639927130
Name:ANDERSON, RYAN JOHN (OD)
Entity type:Individual
Prefix:DR
First Name:RYAN
Middle Name:JOHN
Last Name:ANDERSON
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 1:5446 ARDEN GRV
Mailing Address - Street 2:
Mailing Address - City:COLORADO SPRINGS
Mailing Address - State:CO
Mailing Address - Zip Code:80922-3277
Mailing Address - Country:US
Mailing Address - Phone:218-242-3565
Mailing Address - Fax:
Practice Address - Street 1:3155 N UNION BLVD
Practice Address - Street 2:
Practice Address - City:COLORADO SPRINGS
Practice Address - State:CO
Practice Address - Zip Code:80907-8703
Practice Address - Country:US
Practice Address - Phone:719-630-3937
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2024-05-09
Last Update Date:2024-07-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
COOPT.0004030152W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes152W00000XEye and Vision Services ProvidersOptometrist