Provider Demographics
NPI:1033258959
Name:MARSH, BRYAN VANNUEL (MD)
Entity Type:Individual
Prefix:
First Name:BRYAN
Middle Name:VANNUEL
Last Name:MARSH
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 1:13616 E 103RD ST N
Mailing Address - Street 2:STE A
Mailing Address - City:OWASSO
Mailing Address - State:OK
Mailing Address - Zip Code:74055-4586
Mailing Address - Country:US
Mailing Address - Phone:918-274-8555
Mailing Address - Fax:918-274-8556
Practice Address - Street 1:13616 E 103RD STREET N
Practice Address - Street 2:SUITE A
Practice Address - City:OWASSO
Practice Address - State:OK
Practice Address - Zip Code:74055
Practice Address - Country:US
Practice Address - Phone:918-274-8555
Practice Address - Fax:918-274-8556
Is Sole Proprietor?:No
Enumeration Date:2007-02-06
Last Update Date:2016-12-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OK19507207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
OK100253080AMedicaid
OK$$$$$$$$$-003OtherBLUE CROSS-CLAREMORE
OK$$$$$$$$$-001OtherBLUE CROSS-OWASSO
OK100253080AMedicaid
OK246728805Medicare PIN
OK$$$$$$$$$-002OtherBLUE CROSS-BIXBY