MEDICARE: RYAN S O'CONNOR M.D.

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	207P00000X	Emergency Medicine Physician	A95130	CA

Other Identifiers

#	Provider Identifier	Provider Identifier Type	Provider Identifier State	Provider Identifier Issuer
1	MEDICAID ID Found: Get Medicaid Details using Online Medicaid Verification Program

General Provider Information

NPI Number	:	1821101635
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	RYAN S O'CONNOR M.D.

Provider Business Mailing Address
First Line	:	190 PORTOLA RD
Second Line	:
City	:	PORTOLA VALLEY
State	:	CA
Zip	:	94028-7852
Country	:	US
Telephone Number	:	310-990-9979
Fax Number	:	650-851-4675

Provider Business Practice Location Address
First Line	:	1442 KELLAM AVE
Second Line	:
City	:	LOS ANGELES
State	:	CA
Zip	:	90026-5138
Country	:	US
Telephone Number	:	310-990-9979
Fax Number	:

Authorized Official
Title or Position	:
Name	:
Credential	:
Telephone Number	:

Provider Enumeration Date	:	08/16/2006
Last Update Date	:	09/26/2011

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