Provider Demographics
NPI:1285695528
Name:BRYAN, THOMAS J (OD)
Entity type:Individual
Prefix:DR
First Name:THOMAS
Middle Name:J
Last Name:BRYAN
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 1:1140 POND CURV
Mailing Address - Street 2:
Mailing Address - City:WACONIA
Mailing Address - State:MN
Mailing Address - Zip Code:55387-3103
Mailing Address - Country:US
Mailing Address - Phone:763-498-2751
Mailing Address - Fax:
Practice Address - Street 1:4455 HIGHWAY 169 N
Practice Address - Street 2:
Practice Address - City:PLYMOUTH
Practice Address - State:MN
Practice Address - Zip Code:55442-2897
Practice Address - Country:US
Practice Address - Phone:763-559-7358
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2006-03-28
Last Update Date:2013-09-26
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MN3012152W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes152W00000XEye and Vision Services ProvidersOptometrist
Provider Identifiers
StateIdentifier IDID TypeIssuer
MN915642900Medicaid
V06924Medicare UPIN
MN915642900Medicaid