Provider Demographics
NPI:1740644723
Name:CLAGG, RYAN
Entity type:Individual
Prefix:
First Name:RYAN
Middle Name:
Last Name:CLAGG
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2601 W ALAMEDA AVE STE 416
Mailing Address - Street 2:
Mailing Address - City:BURBANK
Mailing Address - State:CA
Mailing Address - Zip Code:91505-4814
Mailing Address - Country:US
Mailing Address - Phone:818-843-9020
Mailing Address - Fax:818-843-9020
Practice Address - Street 1:2601 W ALAMEDA AVE STE 416
Practice Address - Street 2:
Practice Address - City:BURBANK
Practice Address - State:CA
Practice Address - Zip Code:91505-4814
Practice Address - Country:US
Practice Address - Phone:818-843-9020
Practice Address - Fax:818-843-9020
Is Sole Proprietor?:No
Enumeration Date:2016-04-06
Last Update Date:2020-09-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAA167855208000000X, 207R00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207R00000XAllopathic & Osteopathic PhysiciansInternal Medicine
No208000000XAllopathic & Osteopathic PhysiciansPediatrics