Healthcare Provider Details

I. General information

NPI: 1194130849
Provider Name (Legal Business Name): RYAN JOHN ANDERSON M.D.
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 06/20/2014
Last Update Date: 01/14/2021
Certification Date: 01/14/2021
Deactivation Date:
Reactivation Date:

III. Provider practice location address

411 30TH ST STE 314
OAKLAND CA
94609-3312
US

IV. Provider business mailing address

411 30TH ST STE 314
OAKLAND CA
94609-3312
US

V. Phone/Fax

Practice location:
  • Phone: 510-465-6800
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code390200000X
TaxonomyStudent in an Organized Health Care Education/Training Program
License Number
License Number State
# 2
Primary TaxonomyY
Taxonomy Code207RC0200X
TaxonomyCritical Care Medicine (Internal Medicine) Physician
License NumberA140880
License Number StateCA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: