Provider Demographics
NPI:1962420455
Name:RYAN PETERSON O.D., INC.
Entity type:Organization
Organization Name:RYAN PETERSON O.D., INC.
Other - Org Name:<UNAVAIL>
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:DR
Authorized Official - First Name:RYAN
Authorized Official - Middle Name:KENT
Authorized Official - Last Name:PETERSON
Authorized Official - Suffix:
Authorized Official - Credentials:OD
Authorized Official - Phone:702-299-6200
Mailing Address - Street 1:2208 S RAINBOW BLVD
Mailing Address - Street 2:
Mailing Address - City:LAS VEGAS
Mailing Address - State:NV
Mailing Address - Zip Code:89146-2976
Mailing Address - Country:US
Mailing Address - Phone:702-876-0320
Mailing Address - Fax:702-876-3095
Practice Address - Street 1:2208 S RAINBOW BLVD
Practice Address - Street 2:
Practice Address - City:LAS VEGAS
Practice Address - State:NV
Practice Address - Zip Code:89146-2976
Practice Address - Country:US
Practice Address - Phone:702-876-0320
Practice Address - Fax:702-876-3095
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-07-17
Last Update Date:2009-02-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NV532152W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes152W00000XEye and Vision Services ProvidersOptometristGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
NV100508598Medicaid
NV100506817Medicaid
NVV102450Medicare PIN
NVV09915Medicare UPIN