Provider Demographics
NPI:1174591960
Name:PETTY, RYAN KYLE (OD)
Entity type:Individual
Prefix:DR
First Name:RYAN
Middle Name:KYLE
Last Name:PETTY
Suffix:
Gender:M
Credentials:OD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:488 W HOSPITAL RD
Mailing Address - Street 2:
Mailing Address - City:PAOLI
Mailing Address - State:IN
Mailing Address - Zip Code:47454-8807
Mailing Address - Country:US
Mailing Address - Phone:812-723-4752
Mailing Address - Fax:812-723-4753
Practice Address - Street 1:488 W HOSPITAL RD
Practice Address - Street 2:
Practice Address - City:PAOLI
Practice Address - State:IN
Practice Address - Zip Code:47454-8807
Practice Address - Country:US
Practice Address - Phone:812-723-4752
Practice Address - Fax:812-723-4753
Is Sole Proprietor?:No
Enumeration Date:2006-03-09
Last Update Date:2007-12-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IN18003259A152W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes152W00000XEye and Vision Services ProvidersOptometrist
Provider Identifiers
StateIdentifier IDID TypeIssuer
IN200460220AMedicaid
INU97050Medicare UPIN
IN177080DMedicare PIN