Basic Information
| Provider Information | |||||||||
| NPI: | 1649302621 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | TRAVIS | ||||||||
| FirstName: | RYAN | ||||||||
| MiddleName: | JEFFREY | ||||||||
| NamePrefix: | DR. | ||||||||
| NameSuffix: | |||||||||
| Credential: | M.D. | ||||||||
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| Mailing Information | |||||||||
| Address1: | 790 STREAMVIEW DR | ||||||||
| Address2: | |||||||||
| City: | PERRYSBURG | ||||||||
| State: | OH | ||||||||
| PostalCode: | 435516602 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 4193525387 | ||||||||
| FaxNumber: | 4197250676 | ||||||||
| Practice Location | |||||||||
| Address1: | 710 CLEVELAND AVE | ||||||||
| Address2: | |||||||||
| City: | FREMONT | ||||||||
| State: | OH | ||||||||
| PostalCode: | 434203224 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 4193346619 | ||||||||
| FaxNumber: | 4193346663 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 03/12/2007 | ||||||||
| LastUpdateDate: | 12/11/2019 | ||||||||
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| ProviderGenderCode: | M | ||||||||
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| IsSoleProprietor: | N | ||||||||
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| NPICertificationDate: | 12/11/2019 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 2084P0800X | 35.087855 | OH | Y | Allopathic & Osteopathic Physicians | Psychiatry & Neurology | Psychiatry |
ID Information
| ID | Type | State | Issuer | Description | 2868375 | 05 | OH | MEDICAID |