Basic Information
| Provider Information | |||||||||
| NPI: | 1164477410 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | RYU | ||||||||
| FirstName: | THOMAS | ||||||||
| MiddleName: | K | ||||||||
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| Credential: | DO | ||||||||
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| Mailing Information | |||||||||
| Address1: | 24661 ROYAL RIDGE | ||||||||
| Address2: | |||||||||
| City: | LAGUNA NIGUEL | ||||||||
| State: | CA | ||||||||
| PostalCode: | 92677 | ||||||||
| CountryCode: | US | ||||||||
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| Practice Location | |||||||||
| Address1: | 16200 SAND CANYON AVE | ||||||||
| Address2: | |||||||||
| City: | IRVINE | ||||||||
| State: | CA | ||||||||
| PostalCode: | 926183714 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 9497532000 | ||||||||
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| Other Information | |||||||||
| ProviderEnumerationDate: | 05/24/2006 | ||||||||
| LastUpdateDate: | 02/26/2008 | ||||||||
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| ProviderGenderCode: | M | ||||||||
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| IsSoleProprietor: | N | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 207PE0004X | 20A5251 | CA | Y | Allopathic & Osteopathic Physicians | Emergency Medicine | Emergency Medical Services |
ID Information
| ID | Type | State | Issuer | Description | 00AX52510 | 05 | CA | MEDICAID |