Provider Demographics
NPI:1033151824
Name:O'BRYAN, DEBORAH (MD)
Entity Type:Individual
Prefix:
First Name:DEBORAH
Middle Name:
Last Name:O'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 1:2500 N STATE ST
Mailing Address - Street 2:
Mailing Address - City:JACKSON
Mailing Address - State:MS
Mailing Address - Zip Code:39216-4500
Mailing Address - Country:US
Mailing Address - Phone:601-815-4778
Mailing Address - Fax:601-984-5420
Practice Address - Street 1:2500 N STATE ST
Practice Address - Street 2:
Practice Address - City:JACKSON
Practice Address - State:MS
Practice Address - Zip Code:39216-4500
Practice Address - Country:US
Practice Address - Phone:601-815-4778
Practice Address - Fax:601-984-5420
Is Sole Proprietor?:No
Enumeration Date:2006-06-13
Last Update Date:2014-02-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MS20887207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
TX134259404Medicaid
MSP00795732OtherRAILROAD MEDICARE
MS09173054Medicaid
MS302I088822Medicare PIN
TX81045BMedicare ID - Type Unspecified
TX134259404Medicaid
MSP01197228Medicare PIN
MS302I083658Medicare PIN