Provider Demographics
NPI:1962585968
Name:BRYAN, COLEMAN J JR (MD, MSPH)
Entity type:Individual
Prefix:
First Name:COLEMAN
Middle Name:J
Last Name:BRYAN
Suffix:JR
Gender:M
Credentials:MD, MSPH
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:554 KEILY STREET
Mailing Address - Street 2:
Mailing Address - City:JACKSONVILLE
Mailing Address - State:FL
Mailing Address - Zip Code:32212
Mailing Address - Country:US
Mailing Address - Phone:757-953-7550
Mailing Address - Fax:757-953-7560
Practice Address - Street 1:554 KEILY STREET
Practice Address - Street 2:
Practice Address - City:JACKSONVILLE
Practice Address - State:FL
Practice Address - Zip Code:32212
Practice Address - Country:US
Practice Address - Phone:757-953-7550
Practice Address - Fax:757-953-7560
Is Sole Proprietor?:No
Enumeration Date:2006-10-23
Last Update Date:2017-04-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
VA01012545612080P0207X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2080P0207XAllopathic & Osteopathic PhysiciansPediatricsPediatric Hematology-Oncology
Provider Identifiers
StateIdentifier IDID TypeIssuer
AL009994025Medicaid
AL009993995Medicaid
I29136Medicare UPIN
AL009993995Medicaid