Healthcare Provider Details

I. General information

NPI: 1568617108
Provider Name (Legal Business Name): RYAN B VIETS MD
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 11/24/2008
Last Update Date: 10/02/2020
Certification Date: 10/02/2020
Deactivation Date:
Reactivation Date:

III. Provider practice location address

5555 GROSSMONT CENTER DR
LA MESA CA
91942
US

IV. Provider business mailing address

7777 ALVARADO ROAD # 108
LA MESA CA
91942
US

V. Phone/Fax

Practice location:
  • Phone: 619-740-4034
  • Fax: 619-740-4324
Mailing address:
  • Phone: 619-460-2770
  • Fax: 619-460-2774

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code2085R0202X
TaxonomyDiagnostic Radiology Physician
License NumberA125809
License Number StateCA
# 2
Primary TaxonomyN
Taxonomy Code2085R0202X
TaxonomyDiagnostic Radiology Physician
License Number2012012483
License Number StateMO
# 3
Primary TaxonomyN
Taxonomy Code208600000X
TaxonomySurgery Physician
License NumberA151144
License Number StateCA
# 4
Primary TaxonomyY
Taxonomy Code2085N0700X
TaxonomyNeuroradiology Physician
License NumberA151144
License Number StateCA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: