Provider Demographics
NPI:1104828359
Name:BRYAN, PHILIP CLAY (MD)
Entity Type:Individual
Prefix:
First Name:PHILIP
Middle Name:CLAY
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 1:2204 RAMBLING RD
Mailing Address - Street 2:
Mailing Address - City:EDMOND
Mailing Address - State:OK
Mailing Address - Zip Code:73003-2310
Mailing Address - Country:US
Mailing Address - Phone:405-340-2346
Mailing Address - Fax:
Practice Address - Street 1:2204 RAMBLING RD
Practice Address - Street 2:
Practice Address - City:EDMOND
Practice Address - State:OK
Practice Address - Zip Code:73003-2310
Practice Address - Country:US
Practice Address - Phone:405-340-2346
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2005-06-01
Last Update Date:2015-07-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OK9273174400000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes174400000XOther Service ProvidersSpecialist
Provider Identifiers
StateIdentifier IDID TypeIssuer
OK100000560AMedicaid
OK100000560AMedicaid