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General NPI Number Information
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NPI Number | 1205242500
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Entity Type | Individual
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Provider Name | RYAN ALEXANDER NICHOLAS O.D.
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Gender | Male
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Dates
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Enumeration Date | 07/08/2014
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Last Update Date | 01/20/2015
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Provider Practice Location Address
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Address Line | 574 N US HIGHWAY 441
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City | LADY LAKE
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State | FL
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Zip | 32159-3776
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Country | US
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Telephone | 352-350-5298
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Fax |
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Provider Business Mailing Address
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Address Line | 2524 SAINT IGNATIUS CT
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City | ORLANDO
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State | FL
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Zip | 32835-6500
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Country | US
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Telephone | 909-542-5208
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Fax |
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Authorized Official
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Title or Position |
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Name |
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Credential |
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Telephone |
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 152W00000X
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Taxonomy Name | Optometrist
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License Number | OPC5007
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License Number State | FL
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