Provider Demographics
NPI:1093939746
Name:BRYANT, MARK KEVIN (OD)
Entity Type:Individual
Prefix:DR
First Name:MARK
Middle Name:KEVIN
Last Name:BRYANT
Suffix:
Gender:M
Credentials:OD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:322 WASHINGTON ST
Mailing Address - Street 2:
Mailing Address - City:HOBOKEN
Mailing Address - State:NJ
Mailing Address - Zip Code:07030-4832
Mailing Address - Country:US
Mailing Address - Phone:201-420-0644
Mailing Address - Fax:
Practice Address - Street 1:322 WASHINGTON ST
Practice Address - Street 2:
Practice Address - City:HOBOKEN
Practice Address - State:NJ
Practice Address - Zip Code:07030-4832
Practice Address - Country:US
Practice Address - Phone:201-420-0644
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2007-04-12
Last Update Date:2022-06-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NJ27OA00540100152W00000X, 152WC0802X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes152W00000XEye and Vision Services ProvidersOptometrist
No152WC0802XEye and Vision Services ProvidersOptometristCorneal and Contact Management
Provider Identifiers
StateIdentifier IDID TypeIssuer
NJ223434930OtherTAX IDENTIFICATION NUMBER