Healthcare Provider Details

I. General information

NPI: 1205826393
Provider Name (Legal Business Name): TIMOTHY J RYAN
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 10/28/2005
Last Update Date: 11/09/2010
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

6 W MILL ST
MEDFIELD MA
02052-1507
US

IV. Provider business mailing address

PO BOX 382
MEDFIELD MA
02052-0382
US

V. Phone/Fax

Practice location:
  • Phone: 508-359-7229
  • Fax: 508-359-5363
Mailing address:
  • Phone: 508-359-7229
  • Fax: 508-359-5363

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code213E00000X
TaxonomyPodiatrist
License Number1813
License Number StateMA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: