Provider Demographics
NPI:1932183878
Name:BRYAN, BRADLEY B (MD)
Entity type:Individual
Prefix:
First Name:BRADLEY
Middle Name:B
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 1:1348 NE CUSHING DR STE 201
Mailing Address - Street 2:
Mailing Address - City:BEND
Mailing Address - State:OR
Mailing Address - Zip Code:97701-3876
Mailing Address - Country:US
Mailing Address - Phone:541-382-7696
Mailing Address - Fax:
Practice Address - Street 1:1348 NE CUSHING DR STE 200
Practice Address - Street 2:
Practice Address - City:BEND
Practice Address - State:OR
Practice Address - Zip Code:97701-3876
Practice Address - Country:US
Practice Address - Phone:541-382-7696
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2005-12-05
Last Update Date:2017-02-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
ORMD27365207ZP0102X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207ZP0102XAllopathic & Osteopathic PhysiciansPathologyAnatomic Pathology & Clinical Pathology
Provider Identifiers
StateIdentifier IDID TypeIssuer
ORR138389Medicare PIN