Provider Demographics
NPI:1588896104
Name:DEIBERT, RYAN K (OD)
Entity type:Individual
Prefix:DR
First Name:RYAN
Middle Name:K
Last Name:DEIBERT
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 1:1104 S 74TH ST
Mailing Address - Street 2:
Mailing Address - City:WEST ALLIS
Mailing Address - State:WI
Mailing Address - Zip Code:53214-3007
Mailing Address - Country:US
Mailing Address - Phone:414-550-8530
Mailing Address - Fax:
Practice Address - Street 1:3049 S OAKES RD
Practice Address - Street 2:
Practice Address - City:STURTEVANT
Practice Address - State:WI
Practice Address - Zip Code:53177-1961
Practice Address - Country:US
Practice Address - Phone:414-550-8530
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2009-08-14
Last Update Date:2010-02-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WI3165-035152W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes152W00000XEye and Vision Services ProvidersOptometrist