Provider Demographics
NPI:1982994844
Name:BARRETT, RYAN THOMAS (MD)
Entity Type:Individual
Prefix:
First Name:RYAN
Middle Name:THOMAS
Last Name:BARRETT
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:360 E MALLARD DR
Mailing Address - Street 2:STE 110
Mailing Address - City:BOISE
Mailing Address - State:ID
Mailing Address - Zip Code:83706-3945
Mailing Address - Country:US
Mailing Address - Phone:208-336-8700
Mailing Address - Fax:208-426-0902
Practice Address - Street 1:360 E MALLARD DR
Practice Address - Street 2:STE 110
Practice Address - City:BOISE
Practice Address - State:ID
Practice Address - Zip Code:83706-3945
Practice Address - Country:US
Practice Address - Phone:208-336-8700
Practice Address - Fax:208-426-0902
Is Sole Proprietor?:No
Enumeration Date:2011-04-12
Last Update Date:2016-10-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IDM-13360207W00000X
TXBP10042522207W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207W00000XAllopathic & Osteopathic PhysiciansOphthalmology
Provider Identifiers
StateIdentifier IDID TypeIssuer
ID805858400Medicaid
ID805858400Medicaid