Provider Demographics
NPI:1588756340
Name:VISSER, BRYAN DALE (MD)
Entity type:Individual
Prefix:
First Name:BRYAN
Middle Name:DALE
Last Name:VISSER
Suffix:
Gender:
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
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Other - Credentials:
Mailing Address - Street 1:7901 S 12TH ST
Mailing Address - Street 2:SUITE #200
Mailing Address - City:PORTAGE
Mailing Address - State:MI
Mailing Address - Zip Code:49024-3831
Mailing Address - Country:US
Mailing Address - Phone:269-372-7200
Mailing Address - Fax:269-372-1630
Practice Address - Street 1:7901 S 12TH ST
Practice Address - Street 2:SUITE #200
Practice Address - City:PORTAGE
Practice Address - State:MI
Practice Address - Zip Code:49024-3831
Practice Address - Country:US
Practice Address - Phone:269-372-7200
Practice Address - Fax:269-372-1630
Is Sole Proprietor?:No
Enumeration Date:2006-09-29
Last Update Date:2025-04-09
Deactivation Date:
Deactivation Code:
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Provider Licenses
StateLicense IDTaxonomies
MI4301047094208100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208100000XAllopathic & Osteopathic PhysiciansPhysical Medicine & Rehabilitation
Provider Identifiers
StateIdentifier IDID TypeIssuer
MI2891670Medicaid
MI2891670Medicaid
0M01770Medicare ID - Type Unspecified