Provider Demographics
NPI:1104811512
Name:BRYAN, KEVIN PATRICK (MD)
Entity type:Individual
Prefix:DR
First Name:KEVIN
Middle Name:PATRICK
Last Name:BRYAN
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 1:4200 SUN N LAKE BLVD
Mailing Address - Street 2:
Mailing Address - City:SEBRING
Mailing Address - State:FL
Mailing Address - Zip Code:33872-1986
Mailing Address - Country:US
Mailing Address - Phone:407-975-0412
Mailing Address - Fax:407-975-0407
Practice Address - Street 1:4200 SUN N LAKE BLVD
Practice Address - Street 2:
Practice Address - City:SEBRING
Practice Address - State:FL
Practice Address - Zip Code:33872-1986
Practice Address - Country:US
Practice Address - Phone:407-975-0412
Practice Address - Fax:407-975-0407
Is Sole Proprietor?:Yes
Enumeration Date:2005-09-13
Last Update Date:2020-09-01
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
PAMD417302208000000X
FLME121818208M00000X, 208000000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208000000XAllopathic & Osteopathic PhysiciansPediatrics
No208M00000XAllopathic & Osteopathic PhysiciansHospitalist
Provider Identifiers
StateIdentifier IDID TypeIssuer
FL015608500Medicaid