Provider Demographics
NPI:1063499614
Name:BRYAN, CHARLES L (MD)
Entity Type:Individual
Prefix:DR
First Name:CHARLES
Middle Name:L
Last Name:BRYAN
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 1:435 AIRPORT BLVD
Mailing Address - Street 2:
Mailing Address - City:PENSACOLA
Mailing Address - State:FL
Mailing Address - Zip Code:32503-7847
Mailing Address - Country:US
Mailing Address - Phone:850-435-7448
Mailing Address - Fax:850-435-3156
Practice Address - Street 1:435 AIRPORT BLVD
Practice Address - Street 2:
Practice Address - City:PENSACOLA
Practice Address - State:FL
Practice Address - Zip Code:32503-7847
Practice Address - Country:US
Practice Address - Phone:850-435-7448
Practice Address - Fax:850-435-3156
Is Sole Proprietor?:No
Enumeration Date:2005-12-26
Last Update Date:2012-07-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MS08312207RP1001X
FLME110790207RP1001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207RP1001XAllopathic & Osteopathic PhysiciansInternal MedicinePulmonary Disease
Provider Identifiers
StateIdentifier IDID TypeIssuer
AL592-15571OtherBLUE CROSS BLUE SHIELD
MS00124421Medicaid
AL131501Medicaid
AL592-15573OtherBLUE CROSS BLUE SHIELD
AL131503Medicaid
FL14FJ0OtherBLUE CROSS BLUE SHIELD
AL131504Medicaid
AL592-15574OtherBLUE CROSS BLUE SHIELD
FL003998200Medicaid
AL131501Medicaid
C13893Medicare UPIN
AL131504Medicaid
FL003998200Medicaid