MEDICARE: RYAN PETERSON O.D., INC.

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	532	NV

Other Identifiers

#	Provider Identifier	Provider Identifier Type	Provider Identifier State	Provider Identifier Issuer
1	MEDICAID ID Found: Get Medicaid Details using Online Medicaid Verification Program
2	MEDICAID ID Found: Get Medicaid Details using Online Medicaid Verification Program

General Provider Information

NPI Number	:	1962420455
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	RYAN PETERSON O.D., INC.

Provider Business Mailing Address
First Line	:	2208 S RAINBOW BLVD
Second Line	:
City	:	LAS VEGAS
State	:	NV
Zip	:	89146-2976
Country	:	US
Telephone Number	:	702-876-0320
Fax Number	:	702-876-3095

Provider Business Practice Location Address
First Line	:	2208 S RAINBOW BLVD
Second Line	:
City	:	LAS VEGAS
State	:	NV
Zip	:	89146-2976
Country	:	US
Telephone Number	:	702-876-0320
Fax Number	:	702-876-3095

Authorized Official
Title or Position	:	OWNER
Name	:	DR. RYAN KENT PETERSON
Credential	:	O.D.
Telephone Number	:	702-299-6200

Provider Enumeration Date	:	07/17/2006
Last Update Date	:	02/10/2009

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