Healthcare Provider Details

I. General information

NPI: 1669432969
Provider Name (Legal Business Name): RYAN C VERXAGIO OD
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 03/23/2006
Last Update Date: 02/26/2023
Certification Date: 02/26/2023
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1315 SILK OAK DR
HOLLYWOOD FL
33021-1367
US

IV. Provider business mailing address

1315 SILK OAK DR
HOLLYWOOD FL
33021-1367
US

V. Phone/Fax

Practice location:
  • Phone: 305-439-2015
  • Fax: 305-503-9250
Mailing address:
  • Phone: 305-439-2015
  • Fax: 305-503-9250

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code152WL0500X
TaxonomyLow Vision Rehabilitation Optometrist
License NumberOPC 3957
License Number StateFL
# 2
Primary TaxonomyY
Taxonomy Code152W00000X
TaxonomyOptometrist
License NumberOPC 3957
License Number StateFL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: