Provider Demographics
NPI:1154384824
Name:BRYAN, EMMA LILLIAN (DPM)
Entity type:Individual
Prefix:DR
First Name:EMMA
Middle Name:LILLIAN
Last Name:BRYAN
Suffix:
Gender:F
Credentials:DPM
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:29 S NEW YORK RD
Mailing Address - Street 2:
Mailing Address - City:SMITHVILLE
Mailing Address - State:NJ
Mailing Address - Zip Code:08205
Mailing Address - Country:US
Mailing Address - Phone:609-404-3200
Mailing Address - Fax:609-207-7004
Practice Address - Street 1:29 S NEW YORK RD
Practice Address - Street 2:
Practice Address - City:SMITHVILLE
Practice Address - State:NJ
Practice Address - Zip Code:08205
Practice Address - Country:US
Practice Address - Phone:609-404-3200
Practice Address - Fax:609-207-7004
Is Sole Proprietor?:Yes
Enumeration Date:2006-04-11
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NJ25MD0002522213E00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes213E00000XPodiatric Medicine & Surgery Service ProvidersPodiatrist
Provider Identifiers
StateIdentifier IDID TypeIssuer
NJ8133204Medicaid
NJ8133204Medicaid
U58558Medicare UPIN