Healthcare Provider Details

I. General information

NPI: 1013970474
Provider Name (Legal Business Name): JOHN OLIVER RYAN O.D.
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 04/07/2006
Last Update Date: 04/17/2008
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

306JEFFERSON AVE
WEST JEFFERSON NC
28694-1477
US

IV. Provider business mailing address

PO BOX 1477 306 JEFFERSON AVE
WEST JEFFERSON NC
28694-1477
US

V. Phone/Fax

Practice location:
  • Phone: 336-246-8863
  • Fax: 336-246-8864
Mailing address:
  • Phone: 336-246-8863
  • Fax: 336-246-8864

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code152W00000X
TaxonomyOptometrist
License Number1174
License Number StateNC

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: