Provider Demographics
NPI:1720070568
Name:BRYAN, WESLEY W (MD)
Entity type:Individual
Prefix:
First Name:WESLEY
Middle Name:W
Last Name:BRYAN
Suffix:
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 1:1111 MEDICAL CENTER BLVD
Mailing Address - Street 2:STE. S-650
Mailing Address - City:MARRERO
Mailing Address - State:LA
Mailing Address - Zip Code:70072-3151
Mailing Address - Country:US
Mailing Address - Phone:504-934-8100
Mailing Address - Fax:504-934-8102
Practice Address - Street 1:1111 MEDICAL CENTER BLVD
Practice Address - Street 2:STE. S-650.
Practice Address - City:MARRERO
Practice Address - State:LA
Practice Address - Zip Code:70072-3151
Practice Address - Country:US
Practice Address - Phone:504-934-8100
Practice Address - Fax:504-934-8102
Is Sole Proprietor?:No
Enumeration Date:2005-08-18
Last Update Date:2014-02-24
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
LA023316208800000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208800000XAllopathic & Osteopathic PhysiciansUrology
Provider Identifiers
StateIdentifier IDID TypeIssuer
LA1498891Medicaid
LA4J822CV33Medicare PIN
LA4J822CV33Medicare PIN