Healthcare Provider Details

I. General information

NPI: 1073503843
Provider Name (Legal Business Name): WALTER MATTHEW RYAN III DO
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 10/24/2005
Last Update Date: 08/04/2023
Certification Date: 07/19/2023
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2300 SOUTHWOOD DR
NASHUA NH
03063-1818
US

IV. Provider business mailing address

PO BOX 810
HANOVER NH
03755-0810
US

V. Phone/Fax

Practice location:
  • Phone: 603-577-4000
  • Fax:
Mailing address:
  • Phone: 603-308-1453
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code207K00000X
TaxonomyAllergy & Immunology Physician
License NumberOS10177
License Number StateFL
# 2
Primary TaxonomyY
Taxonomy Code207RA0201X
TaxonomyAllergy & Immunology (Internal Medicine) Physician
License Number24463
License Number StateNH

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: