Healthcare Provider Details

I. General information

NPI: 1295028058
Provider Name (Legal Business Name): RYAN JEFFREY HEADY O.D.
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 05/25/2011
Last Update Date: 09/27/2018
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1229 E SEMINOLE ST STE 430
SPRINGFIELD MO
65804-2227
US

IV. Provider business mailing address

1229 E SEMINOLE ST STE 430
SPRINGFIELD MO
65804-2227
US

V. Phone/Fax

Practice location:
  • Phone: 417-820-9393
  • Fax: 260-569-0760
Mailing address:
  • Phone: 417-820-9393
  • Fax: 260-569-0760

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code152W00000X
TaxonomyOptometrist
License Number18003832
License Number StateIN
# 2
Primary TaxonomyY
Taxonomy Code152W00000X
TaxonomyOptometrist
License Number2013000334
License Number StateMO

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: