Provider Demographics
NPI:1073624540
Name:BRYAN, EDWIN D (OD)
Entity Type:Individual
Prefix:DR
First Name:EDWIN
Middle Name:D
Last Name:BRYAN
Suffix:
Gender:M
Credentials:OD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
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Mailing Address - Street 1:12930 MARY ANN BEACH RD
Mailing Address - Street 2:
Mailing Address - City:FAIRHOPE
Mailing Address - State:AL
Mailing Address - Zip Code:36532-5423
Mailing Address - Country:US
Mailing Address - Phone:251-929-3191
Mailing Address - Fax:251-937-1397
Practice Address - Street 1:701 MCMEANS AVE
Practice Address - Street 2:
Practice Address - City:BAY MINETTE
Practice Address - State:AL
Practice Address - Zip Code:36507-3337
Practice Address - Country:US
Practice Address - Phone:251-937-1455
Practice Address - Fax:251-937-1397
Is Sole Proprietor?:Yes
Enumeration Date:2006-08-31
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
ALS-490-TA-140152W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes152W00000XEye and Vision Services ProvidersOptometrist
Provider Identifiers
StateIdentifier IDID TypeIssuer
ALT69145Medicare UPIN