Provider Demographics
NPI:1871047613
Name:KWAN, RYAN (OD)
Entity type:Individual
Prefix:DR
First Name:RYAN
Middle Name:
Last Name:KWAN
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 1:198 SW BROAD ST
Mailing Address - Street 2:
Mailing Address - City:JESUP
Mailing Address - State:GA
Mailing Address - Zip Code:31545-1101
Mailing Address - Country:US
Mailing Address - Phone:912-530-6000
Mailing Address - Fax:912-530-6044
Practice Address - Street 1:4875 ALTAMA AVE
Practice Address - Street 2:
Practice Address - City:BRUNSWICK
Practice Address - State:GA
Practice Address - Zip Code:31520-2912
Practice Address - Country:US
Practice Address - Phone:912-554-0010
Practice Address - Fax:912-554-0075
Is Sole Proprietor?:Yes
Enumeration Date:2016-08-10
Last Update Date:2021-01-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GAOPT002966152W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes152W00000XEye and Vision Services ProvidersOptometrist