Provider Demographics
NPI:1972630259
Name:BRYAN, LAURAN (MD)
Entity type:Individual
Prefix:
First Name:LAURAN
Middle Name:
Last Name:BRYAN
Suffix:
Gender:F
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:27209 LAHSER RD
Mailing Address - Street 2:
Mailing Address - City:SOUTHFIELD
Mailing Address - State:MI
Mailing Address - Zip Code:48034-8401
Mailing Address - Country:US
Mailing Address - Phone:248-356-5815
Mailing Address - Fax:248-356-5830
Practice Address - Street 1:26711 WOODWARD AVE STE LL1
Practice Address - Street 2:
Practice Address - City:HUNTINGTON WOODS
Practice Address - State:MI
Practice Address - Zip Code:48070-1370
Practice Address - Country:US
Practice Address - Phone:248-584-0044
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2007-02-27
Last Update Date:2015-07-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI43010584622086S0122X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2086S0122XAllopathic & Osteopathic PhysiciansSurgeryPlastic and Reconstructive Surgery
Provider Identifiers
StateIdentifier IDID TypeIssuer
MIF66121Medicare UPIN