Provider Demographics
NPI:1104828359
Name:BRYAN, PHILIP CLAY (MD)
Entity type:Individual
Prefix:
First Name:PHILIP
Middle Name:CLAY
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 1:1515 TOWER DR
Mailing Address - Street 2:
Mailing Address - City:MOORE
Mailing Address - State:OK
Mailing Address - Zip Code:73160-6181
Mailing Address - Country:US
Mailing Address - Phone:405-310-0836
Mailing Address - Fax:405-758-5582
Practice Address - Street 1:1000 N LEE AVE
Practice Address - Street 2:
Practice Address - City:OKLAHOMA CITY
Practice Address - State:OK
Practice Address - Zip Code:73102-1036
Practice Address - Country:US
Practice Address - Phone:405-340-2346
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2005-06-01
Last Update Date:2024-05-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OK9273208600000X, 174400000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes174400000XOther Service ProvidersSpecialist
No208600000XAllopathic & Osteopathic PhysiciansSurgery
Provider Identifiers
StateIdentifier IDID TypeIssuer
OK100000560AMedicaid
OK100000560AMedicaid