Provider Demographics
NPI:1952408007
Name:RYAN, COLLEEN M (MD)
Entity type:Individual
Prefix:
First Name:COLLEEN
Middle Name:M
Last Name:RYAN
Suffix:
Gender:F
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
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Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:9201 W SUNSET BLVD STE 701
Mailing Address - Street 2:
Mailing Address - City:LOS ANGELES
Mailing Address - State:CA
Mailing Address - Zip Code:90069-3708
Mailing Address - Country:US
Mailing Address - Phone:310-855-2558
Mailing Address - Fax:303-441-2388
Practice Address - Street 1:9201 W SUNSET BLVD STE 701
Practice Address - Street 2:
Practice Address - City:LOS ANGELES
Practice Address - State:CA
Practice Address - Zip Code:90069-3708
Practice Address - Country:US
Practice Address - Phone:310-855-2558
Practice Address - Fax:888-747-2520
Is Sole Proprietor?:No
Enumeration Date:2006-09-20
Last Update Date:2022-09-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAC133544207Q00000X, 207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
CO45007071Medicaid
BR9389506OtherDEA
BR9389506OtherDEA
COCOA105320Medicare PIN