Basic Information
| Provider Information | |||||||||
| NPI: | 1164849964 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | ANDERSON | ||||||||
| FirstName: | RYAN | ||||||||
| MiddleName: | |||||||||
| NamePrefix: | DR. | ||||||||
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| Credential: | O.D. | ||||||||
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| Mailing Information | |||||||||
| Address1: | 72057 DINAH SHORE DR | ||||||||
| Address2: | SUITE D | ||||||||
| City: | RANCHO MIRAGE | ||||||||
| State: | CA | ||||||||
| PostalCode: | 922701791 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7603403937 | ||||||||
| FaxNumber: | 7603274313 | ||||||||
| Practice Location | |||||||||
| Address1: | 555 E TACHEVAH DR | ||||||||
| Address2: | SUITE 101E | ||||||||
| City: | PALM SPRINGS | ||||||||
| State: | CA | ||||||||
| PostalCode: | 922625750 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7603271561 | ||||||||
| FaxNumber: | 7603274313 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 03/19/2014 | ||||||||
| LastUpdateDate: | 08/10/2015 | ||||||||
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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 | 152W00000X | OPT 15050 TLG | CA | Y | Eye and Vision Services Providers | Optometrist |
No ID Information.