Provider Demographics
NPI:1063496644
Name:BRYAN, JULIE (MD)
Entity Type:Individual
Prefix:
First Name:JULIE
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 1:11109 PARKVIEW PLAZA DR # 117
Mailing Address - Street 2:
Mailing Address - City:FORT WAYNE
Mailing Address - State:IN
Mailing Address - Zip Code:46845-1701
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:1818 CAREW ST
Practice Address - Street 2:SUITE 260
Practice Address - City:FORT WAYNE
Practice Address - State:IN
Practice Address - Zip Code:46805-4788
Practice Address - Country:US
Practice Address - Phone:260-373-9250
Practice Address - Fax:260-373-9262
Is Sole Proprietor?:No
Enumeration Date:2005-12-06
Last Update Date:2023-04-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IN01053541A207R00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207R00000XAllopathic & Osteopathic PhysiciansInternal Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
IN200330130Medicaid
IN3937240010OtherMEDICARE DMEPOS
IN12156OtherPHYSICIANS HEALTH PLAN
INP00204040OtherMEDICARE RR
IN000000358544OtherANTHEM
7318238OtherAETNA
IN12156OtherPHYSICIANS HEALTH PLAN
INP00204040Medicare PIN
IN200330130Medicaid
IN070860QQQMedicare UPIN
INP00204040OtherMEDICARE RR