Provider Demographics
NPI:1558657783
Name:HUBER, RYAN DOUGLAS (OD)
Entity type:Individual
Prefix:DR
First Name:RYAN
Middle Name:DOUGLAS
Last Name:HUBER
Suffix:
Gender:M
Credentials:OD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
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Other - Credentials:
Mailing Address - Street 1:27 N FISHER PARK WAY STE 101
Mailing Address - Street 2:
Mailing Address - City:EAGLE
Mailing Address - State:ID
Mailing Address - Zip Code:83616-4795
Mailing Address - Country:US
Mailing Address - Phone:208-514-1858
Mailing Address - Fax:208-576-6951
Practice Address - Street 1:27 N FISHER PARK WAY STE 101
Practice Address - Street 2:
Practice Address - City:EAGLE
Practice Address - State:ID
Practice Address - Zip Code:83616-4795
Practice Address - Country:US
Practice Address - Phone:208-514-1858
Practice Address - Fax:844-840-3190
Is Sole Proprietor?:No
Enumeration Date:2011-06-27
Last Update Date:2022-05-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IDODP-100228152W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes152W00000XEye and Vision Services ProvidersOptometrist
Provider Identifiers
StateIdentifier IDID TypeIssuer
ID1558657783Medicaid
1594527Medicare PIN