MEDICARE: DR. RYAN STEPHEN VIDA O.D

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	152W00000X	Optometrist	2947	TN
2	152WC0802X	Corneal and Contact Management Optometrist	2947	TN
3	152W00000X	Optometrist	14584	CA

General Provider Information

NPI Number	:	1568777076
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	DR. RYAN STEPHEN VIDA O.D

Provider Business Mailing Address
First Line	:	4353 PARK TERRACE DR
Second Line	:	STE 150
City	:	WESTLAKE VILLAGE
State	:	CA
Zip	:	91361-4631
Country	:	US
Telephone Number	:	805-987-5300
Fax Number	:	805-987-5330

Provider Business Practice Location Address
First Line	:	4353 PARK TERRACE DR
Second Line	:	STE 150
City	:	WESTLAKE VILLAGE
State	:	CA
Zip	:	91361-4631
Country	:	US
Telephone Number	:	805-987-5300
Fax Number	:	805-987-5330

Authorized Official
Title or Position	:
Name	:
Credential	:
Telephone Number	:

Provider Enumeration Date	:	08/10/2010
Last Update Date	:	10/23/2013

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