Provider Demographics
NPI:1699700864
Name:BRYANT, GLEN EDWARD JR (MD)
Entity type:Individual
Prefix:
First Name:GLEN
Middle Name:EDWARD
Last Name:BRYANT
Suffix:JR
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 1:303 W POLK
Mailing Address - Street 2:SUITE A
Mailing Address - City:WEST MEMPHIS
Mailing Address - State:AR
Mailing Address - Zip Code:72301
Mailing Address - Country:US
Mailing Address - Phone:870-732-2100
Mailing Address - Fax:870-732-3027
Practice Address - Street 1:303 W POLK
Practice Address - Street 2:SUITE A
Practice Address - City:WEST MEMPHIS
Practice Address - State:AR
Practice Address - Zip Code:72301
Practice Address - Country:US
Practice Address - Phone:870-732-2100
Practice Address - Fax:870-732-3027
Is Sole Proprietor?:Yes
Enumeration Date:2006-07-12
Last Update Date:2014-12-19
Deactivation Date:
Deactivation Code:
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Provider Licenses
StateLicense IDTaxonomies
ARC5746207W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207W00000XAllopathic & Osteopathic PhysiciansOphthalmology
Provider Identifiers
StateIdentifier IDID TypeIssuer
AR102003001Medicaid
D84094Medicare UPIN
AR102003001Medicaid