MEDICARE: DR. RYAN K DEIBERT 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	3165-035	WI

General Provider Information

NPI Number	:	1588896104
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	DR. RYAN K DEIBERT O.D.

Provider Business Mailing Address
First Line	:	1104 S 74TH ST
Second Line	:
City	:	WEST ALLIS
State	:	WI
Zip	:	53214-3007
Country	:	US
Telephone Number	:	414-550-8530
Fax Number	:

Provider Business Practice Location Address
First Line	:	3049 S OAKES RD
Second Line	:
City	:	STURTEVANT
State	:	WI
Zip	:	53177-1961
Country	:	US
Telephone Number	:	414-550-8530
Fax Number	:

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

Provider Enumeration Date	:	08/14/2009
Last Update Date	:	02/18/2010

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