Basic Information
Provider Information | |||||||||
NPI: | 1891748984 | ||||||||
EntityType: | 1 | ||||||||
ReplacementNPI: |   | ||||||||
OrganizationName: |   | ||||||||
LastName: | RYAN | ||||||||
FirstName: | REBECCA | ||||||||
MiddleName: | D. | ||||||||
NamePrefix: | DR. | ||||||||
NameSuffix: |   | ||||||||
Credential: | O.D. | ||||||||
OtherOrganizationName: |   | ||||||||
OtherOrganizationType: |   | ||||||||
OtherLastName: |   | ||||||||
OtherFirstName: |   | ||||||||
OtherMiddleName: |   | ||||||||
OtherNamePrefix: |   | ||||||||
OtherNameSuffix: |   | ||||||||
OtherCredential: |   | ||||||||
OtherLastNameType: |   | ||||||||
Mailing Information | |||||||||
Address1: | 8309 N KNOXVILLE AVE | ||||||||
Address2: |   | ||||||||
City: | PEORIA | ||||||||
State: | IL | ||||||||
PostalCode: | 616152170 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 3096939540 | ||||||||
FaxNumber: | 3096939754 | ||||||||
Practice Location | |||||||||
Address1: | 901 W MORTON AVE | ||||||||
Address2: | STE. 113 | ||||||||
City: | JACKSONVILLE | ||||||||
State: | IL | ||||||||
PostalCode: | 626503145 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 2172436506 | ||||||||
FaxNumber: | 2172434902 | ||||||||
Other Information | |||||||||
ProviderEnumerationDate: | 05/18/2006 | ||||||||
LastUpdateDate: | 10/23/2015 | ||||||||
NPIDeactivationReasonCode: |   | ||||||||
NPIDeactivationDate: |   | ||||||||
NPIReactivationDate: |   | ||||||||
ProviderGenderCode: | F | ||||||||
AuthorizedOfficialLastName: |   | ||||||||
AuthorizedOfficialFirstName: |   | ||||||||
AuthorizedOfficialMiddleName: |   | ||||||||
AuthorizedOfficialTitleorPosition: |   | ||||||||
AuthorizedOfficialTelephone: |   | ||||||||
IsSoleProprietor: | N | ||||||||
IsOrganizationSubpart: |   | ||||||||
ParentOrganizationLBN: |   | ||||||||
AuthorizedOfficialNamePrefix: |   | ||||||||
AuthorizedOfficialNameSuffix: |   | ||||||||
AuthorizedOfficialCredential: |   | ||||||||
NPICertificationDate: |   |
Taxonomy Information
Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 152W00000X | 046008280 | IL | Y |   | Eye and Vision Services Providers | Optometrist |   |
No ID Information.