Healthcare Provider Details

I. General information

NPI: 1699042507
Provider Name (Legal Business Name): MANIJEH RYAN MD INC A PROFESSIONAL CORPORATION
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 11/20/2011
Last Update Date: 06/09/2022
Certification Date: 06/09/2022
Deactivation Date:
Reactivation Date:

III. Provider practice location address

3838 WATT AVE STE D404
SACRAMENTO CA
95821-2665
US

IV. Provider business mailing address

PO BOX 3765
WALNUT CREEK CA
94598-0765
US

V. Phone/Fax

Practice location:
  • Phone: 925-765-7761
  • Fax: 510-344-2556
Mailing address:
  • Phone: 925-349-5158
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code208VP0014X
TaxonomyInterventional Pain Medicine Physician
License NumberA117409
License Number StateCA
# 2
Primary TaxonomyN
Taxonomy Code2081N0008X
TaxonomyNeuromuscular Medicine (Physical Medicine & Rehabilitation) Physician
License NumberA117409
License Number StateCA
# 3
Primary TaxonomyN
Taxonomy Code2081P0301X
TaxonomyBrain Injury Medicine (Physical Medicine & Rehabilitation) Physician
License Number
License Number State
# 4
Primary TaxonomyY
Taxonomy Code2081P2900X
TaxonomyPain Medicine (Physical Medicine & Rehabilitation) Physician
License NumberA117409
License Number StateCA

VIII. Authorized Official

Name: MANIJEH RYAN
Title or Position: PRESIDENT/MEDICAL DIRECTOR
Credential: MD
Phone: 925-765-7761