Provider Demographics
NPI:1063623502
Name:ROSEDALE, BRYAN DAVID (MD)
Entity type:Individual
Prefix:DR
First Name:BRYAN
Middle Name:DAVID
Last Name:ROSEDALE
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:165 BEECH SPRINGS RD
Mailing Address - Street 2:
Mailing Address - City:JONESBORO
Mailing Address - State:LA
Mailing Address - Zip Code:71251-2013
Mailing Address - Country:US
Mailing Address - Phone:318-259-4435
Mailing Address - Fax:
Practice Address - Street 1:165 BEECH SPRINGS RD
Practice Address - Street 2:
Practice Address - City:JONESBORO
Practice Address - State:LA
Practice Address - Zip Code:71251-2013
Practice Address - Country:US
Practice Address - Phone:318-259-4435
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2007-05-25
Last Update Date:2022-07-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
LAMD.026024207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
LA05611Medicaid