Healthcare Provider Details

I. General information

NPI: 1609946847
Provider Name (Legal Business Name): JOHN ILSUN RYU O.D.
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 11/08/2006
Last Update Date: 07/15/2024
Certification Date: 07/15/2024
Deactivation Date:
Reactivation Date:

III. Provider practice location address

690 E LOS ANGELES AVE SUITE A
SIMI VALLEY CA
93065-1857
US

IV. Provider business mailing address

1194 KNOTTINGHAM ST
SIMI VALLEY CA
93065-5167
US

V. Phone/Fax

Practice location:
  • Phone: 626-376-3513
  • Fax: 905-250-1001
Mailing address:
  • Phone: 626-376-3513
  • Fax: 805-250-1001

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code152W00000X
TaxonomyOptometrist
License Number11209T
License Number StateCA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: