Provider Demographics
NPI:1215317524
Name:RYAN D. HUBER, O.D., P.A.
Entity type:Organization
Organization Name:RYAN D. HUBER, O.D., P.A.
Other - Org Name:<UNAVAIL>
Other - Org Type:
Authorized Official - Title/Position:OPTOMETRIST/OWNER
Authorized Official - Prefix:DR
Authorized Official - First Name:RYAN
Authorized Official - Middle Name:DOUGLAS
Authorized Official - Last Name:HUBER
Authorized Official - Suffix:
Authorized Official - Credentials:OD
Authorized Official - Phone:208-514-1858
Mailing Address - Street 1:27 N FISHER PARK WAY
Mailing Address - Street 2:SUITE 101
Mailing Address - City:EAGLE
Mailing Address - State:ID
Mailing Address - Zip Code:83616-4796
Mailing Address - Country:US
Mailing Address - Phone:208-514-1858
Mailing Address - Fax:844-840-3190
Practice Address - Street 1:27 N FISHER PARK WAY
Practice Address - Street 2:SUITE 101
Practice Address - City:EAGLE
Practice Address - State:ID
Practice Address - Zip Code:83616-4796
Practice Address - Country:US
Practice Address - Phone:208-514-1858
Practice Address - Fax:844-840-3190
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2015-06-02
Last Update Date:2016-03-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IDODP-100228152W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes152W00000XEye and Vision Services ProvidersOptometristGroup - Single Specialty