1538103148 NPI number — DR. RYAN E NIELSON OD

Table of content: DR. RYAN E NIELSON OD (NPI 1538103148)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1538103148 NPI number — DR. RYAN E NIELSON OD

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
Provider Last Name:
NIELSON
Provider First Name:
RYAN
Provider Middle Name:
E
Provider Name Prefix Text:
DR.
Provider Name Suffix Text:
Provider Credential Text:
OD
Provider Gender Code:
M

Provider's Other Name Information

Provider Other Organization Name:
Provider Other Organization Name Type Code:
Provider Other Last Name:
Provider Other First Name:
Provider Other Middle Name:
Provider Other Name Prefix Text:
Provider Other Name Suffix Text:
Provider Other Credential Text:
Provider Other Last Name Type Code:

NPI Number Information

NPI Number:
1538103148
Entity Type Code:
Individual
Replacement NPI:
Last Update Date:
09/10/2024
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
2320 E GALA ST
Provider Second Line Business Mailing Address:
SUITE 400
Provider Business Mailing Address City Name:
MERIDIAN
Provider Business Mailing Address State Name:
ID
Provider Business Mailing Address Postal Code:
83642-7091
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
208-898-0304
Provider Business Mailing Address Fax Number:

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
1715 S WELLS AVE
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
MERIDIAN
Provider Business Practice Location Address State Name:
ID
Provider Business Practice Location Address Postal Code:
83642-5756
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
208-898-0304
Provider Business Practice Location Address Fax Number:
208-898-0380
Provider Enumeration Date:
06/15/2006

Additional Information

Authorized Official

Authorized Official Last Name:
Authorized Official First Name:
Authorized Official Middle Name:
Authorized Official Title or Position:
Authorized Official Telephone Number:

Provider Taxonomy Codes

  • Taxonomy code: 152W00000X , with the licence number:  ODP-100015 , registered in the state of ID ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

Other Provider's Identifiers (legacy, non-NPI)

  • Identifier: 806418901 , issued by the state of ( ID ) . This identifiers is of the category "MEDICAID".
  • Identifier: 806418900 , issued by the state of ( ID ) . This identifiers is of the category "MEDICAID".
  • Identifier: V6945 . This is a "BLUE CROSS GROUP #" identifier , issued by the state of ( ID ) . This identifiers is of the category "OTHER".
  • Identifier: 000010139527 . This is a "BLUE SHIELD OF IDAHO" identifier , issued by the state of ( ID ) . This identifiers is of the category "OTHER".
  • Identifier: V6952 . This is a "BLUE CROSS IDAHO" identifier , issued by the state of ( ID ) . This identifiers is of the category "OTHER".




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