Provider Demographics
NPI:1104947431
Name:RYAN, JOSEPH VINCENT (OD)
Entity type:Individual
Prefix:DR
First Name:JOSEPH
Middle Name:VINCENT
Last Name:RYAN
Suffix:
Gender:M
Credentials:OD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:3073 E PARK AVE
Mailing Address - Street 2:
Mailing Address - City:GILBERT
Mailing Address - State:AZ
Mailing Address - Zip Code:85234-6362
Mailing Address - Country:US
Mailing Address - Phone:602-508-1689
Mailing Address - Fax:602-952-7117
Practice Address - Street 1:4502 E OAK ST
Practice Address - Street 2:AT COSTCO
Practice Address - City:PHOENIX
Practice Address - State:AZ
Practice Address - Zip Code:85008-2411
Practice Address - Country:US
Practice Address - Phone:602-508-1689
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2007-04-03
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AZ701152W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes152W00000XEye and Vision Services ProvidersOptometrist
Provider Identifiers
StateIdentifier IDID TypeIssuer
60110OtherPIN
T76904Medicare UPIN