Provider Demographics
NPI:1063605384
Name:PEDERSON, RYAN D (DPM)
Entity type:Individual
Prefix:
First Name:RYAN
Middle Name:D
Last Name:PEDERSON
Suffix:
Gender:M
Credentials:DPM
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1900 WOODLAND DR
Mailing Address - Street 2:
Mailing Address - City:COOS BAY
Mailing Address - State:OR
Mailing Address - Zip Code:97420-2099
Mailing Address - Country:US
Mailing Address - Phone:541-269-5151
Mailing Address - Fax:541-266-4506
Practice Address - Street 1:1900 WOODLAND DR
Practice Address - Street 2:
Practice Address - City:COOS BAY
Practice Address - State:OR
Practice Address - Zip Code:97420-2099
Practice Address - Country:US
Practice Address - Phone:541-267-5151
Practice Address - Fax:541-266-4506
Is Sole Proprietor?:Yes
Enumeration Date:2007-08-21
Last Update Date:2020-03-30
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
ORDP151127213ES0103X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes213ES0103XPodiatric Medicine & Surgery Service ProvidersPodiatristFoot & Ankle Surgery
Provider Identifiers
StateIdentifier IDID TypeIssuer
OR500623170Medicaid
ORR0000WCSBVMedicare PIN