Provider Demographics
NPI:1881778637
Name:RYAN, JEFFREY (DO)
Entity type:Individual
Prefix:DR
First Name:JEFFREY
Middle Name:
Last Name:RYAN
Suffix:
Gender:M
Credentials:DO
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:9936 AZALEA BLOOM WAY APT 404
Mailing Address - Street 2:
Mailing Address - City:RIVERVIEW
Mailing Address - State:FL
Mailing Address - Zip Code:33578-4629
Mailing Address - Country:US
Mailing Address - Phone:518-852-3955
Mailing Address - Fax:
Practice Address - Street 1:244 SAINT AUGUSTINE AVE APT 101
Practice Address - Street 2:
Practice Address - City:VENICE
Practice Address - State:FL
Practice Address - Zip Code:34285-1839
Practice Address - Country:US
Practice Address - Phone:518-852-3955
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2006-10-25
Last Update Date:2024-06-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLOS20961207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
NY02243176Medicaid
NYCC7013Medicare PIN
NYG51764Medicare UPIN