Provider Demographics
NPI:1700144029
Name:THOELE, RYAN SCOTT (OD)
Entity Type:Individual
Prefix:DR
First Name:RYAN
Middle Name:SCOTT
Last Name:THOELE
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 1:2445 BROADWAY ST
Mailing Address - Street 2:
Mailing Address - City:QUINCY
Mailing Address - State:IL
Mailing Address - Zip Code:62301-3257
Mailing Address - Country:US
Mailing Address - Phone:217-222-8800
Mailing Address - Fax:217-222-8801
Practice Address - Street 1:1505 W MAIN ST
Practice Address - Street 2:
Practice Address - City:MT ZION
Practice Address - State:IL
Practice Address - Zip Code:62549-1300
Practice Address - Country:US
Practice Address - Phone:217-864-3221
Practice Address - Fax:217-596-4670
Is Sole Proprietor?:No
Enumeration Date:2012-04-24
Last Update Date:2018-02-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL046010469152W00000X
MO2013000824152W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes152W00000XEye and Vision Services ProvidersOptometrist
Provider Identifiers
StateIdentifier IDID TypeIssuer
IL1700144029Medicaid
MO1700144029Medicaid