Provider Demographics
NPI:1316070717
Name:EGO-OSUALA, BRYAN C (MD)
Entity type:Individual
Prefix:DR
First Name:BRYAN
Middle Name:C
Last Name:EGO-OSUALA
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
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Other - Credentials:
Mailing Address - Street 1:10 SAINT PATRICKS DR
Mailing Address - Street 2:
Mailing Address - City:WALDORF
Mailing Address - State:MD
Mailing Address - Zip Code:20603-4527
Mailing Address - Country:US
Mailing Address - Phone:301-373-7900
Mailing Address - Fax:301-373-6900
Practice Address - Street 1:10 SAINT PATRICKS DR
Practice Address - Street 2:
Practice Address - City:WALDORF
Practice Address - State:MD
Practice Address - Zip Code:20603-4527
Practice Address - Country:US
Practice Address - Phone:301-373-7900
Practice Address - Fax:301-373-6900
Is Sole Proprietor?:No
Enumeration Date:2007-03-14
Last Update Date:2021-12-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NC2014-00330207Y00000X
MDD71707207Y00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Y00000XAllopathic & Osteopathic PhysiciansOtolaryngology
Provider Identifiers
StateIdentifier IDID TypeIssuer
6079386OtherCIGNA
MD331216000Medicaid
SCNC2120OtherMEDICAID - SC
NCP01671244OtherRAILROAD MEDICARE
SC1046720OtherWELLCARE OF SC
1479753OtherAETNA/COVENTRY
NC187LAOtherBCBSNC