Provider Demographics
NPI:1427170596
Name:RYAN, TIMOTHEA A (MD)
Entity type:Individual
Prefix:
First Name:TIMOTHEA
Middle Name:A
Last Name:RYAN
Suffix:
Gender:F
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:546 S BROAD ST
Mailing Address - Street 2:
Mailing Address - City:MERIDEN
Mailing Address - State:CT
Mailing Address - Zip Code:06450-6600
Mailing Address - Country:US
Mailing Address - Phone:203-235-2511
Mailing Address - Fax:203-639-0809
Practice Address - Street 1:546 S BROAD ST
Practice Address - Street 2:SUITE 1D
Practice Address - City:MERIDEN
Practice Address - State:CT
Practice Address - Zip Code:06450
Practice Address - Country:US
Practice Address - Phone:203-235-2511
Practice Address - Fax:203-639-0809
Is Sole Proprietor?:No
Enumeration Date:2007-04-06
Last Update Date:2022-02-04
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CT046408207W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207W00000XAllopathic & Osteopathic PhysiciansOphthalmology
Provider Identifiers
StateIdentifier IDID TypeIssuer
CT1427170596Medicaid
CTP00678638OtherRAIL ROAD MEDICARE
010046408CT01OtherANTHEM