Provider Demographics
NPI:1750392742
Name:HIESTERMAN, RYAN LEE (OD)
Entity type:Individual
Prefix:DR
First Name:RYAN
Middle Name:LEE
Last Name:HIESTERMAN
Suffix:
Gender:M
Credentials:OD
Other - Prefix:
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Other - Credentials:
Mailing Address - Street 1:8305 MELROSE DR
Mailing Address - Street 2:
Mailing Address - City:LENEXA
Mailing Address - State:KS
Mailing Address - Zip Code:66214-1629
Mailing Address - Country:US
Mailing Address - Phone:785-632-6100
Mailing Address - Fax:913-340-9880
Practice Address - Street 1:629 W CRAWFORD ST
Practice Address - Street 2:
Practice Address - City:CLAY CENTER
Practice Address - State:KS
Practice Address - Zip Code:67432-2337
Practice Address - Country:US
Practice Address - Phone:785-632-6100
Practice Address - Fax:785-630-5830
Is Sole Proprietor?:No
Enumeration Date:2006-08-11
Last Update Date:2023-01-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
KS1656152W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes152W00000XEye and Vision Services ProvidersOptometrist
Provider Identifiers
StateIdentifier IDID TypeIssuer
KSP00173182OtherRAILROAD MEDICARE (24K)
KS065087OtherBLUE CROSS BLUE SHIELD KS
KS200259350BMedicaid
KS47-0944087OtherSUPERIOR VISION
KS481170OtherFIRSTGUARD
KS651020OtherBCBS OF KS PIN #
KS065087Medicare ID - Type UnspecifiedBOX 33 GROUP
KS651020Medicare PIN
KS200259350BMedicaid
KS651020OtherBCBS OF KS PIN #