Provider Demographics
NPI:1083651988
Name:LALLATHIN, BRYAN EDWARD (OD)
Entity type:Individual
Prefix:DR
First Name:BRYAN
Middle Name:EDWARD
Last Name:LALLATHIN
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 1:4800 N 22ND ST STE 210
Mailing Address - Street 2:
Mailing Address - City:PHOENIX
Mailing Address - State:AZ
Mailing Address - Zip Code:85016-4963
Mailing Address - Country:US
Mailing Address - Phone:602-598-7488
Mailing Address - Fax:602-508-4830
Practice Address - Street 1:1400 COMMON DR
Practice Address - Street 2:
Practice Address - City:EL PASO
Practice Address - State:TX
Practice Address - Zip Code:79936-5922
Practice Address - Country:US
Practice Address - Phone:915-267-2020
Practice Address - Fax:915-595-4460
Is Sole Proprietor?:No
Enumeration Date:2006-05-31
Last Update Date:2021-11-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TX5069TG152W00000X
OK2133152W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes152W00000XEye and Vision Services ProvidersOptometrist