Provider Demographics
NPI:1104860691
Name:LUM, BRYANT JAY (MD)
Entity Type:Individual
Prefix:
First Name:BRYANT
Middle Name:JAY
Last Name:LUM
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 1:3088 TELEGRAPH RD
Mailing Address - Street 2:SUITE A
Mailing Address - City:VENTURA
Mailing Address - State:CA
Mailing Address - Zip Code:93003-3234
Mailing Address - Country:US
Mailing Address - Phone:805-648-6891
Mailing Address - Fax:805-648-6386
Practice Address - Street 1:3088 TELEGRAPH RD
Practice Address - Street 2:SUITE A
Practice Address - City:VENTURA
Practice Address - State:CA
Practice Address - Zip Code:93003-3234
Practice Address - Country:US
Practice Address - Phone:805-648-6891
Practice Address - Fax:805-648-6386
Is Sole Proprietor?:Yes
Enumeration Date:2006-06-15
Last Update Date:2010-12-22
Deactivation Date:
Deactivation Code:
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Provider Licenses
StateLicense IDTaxonomies
CAA45040207W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207W00000XAllopathic & Osteopathic PhysiciansOphthalmology
Provider Identifiers
StateIdentifier IDID TypeIssuer
CAZZZ41333ZOtherBLUE SHIELD
CAW12217Medicare ID - Type Unspecified
CAZZZ41333ZOtherBLUE SHIELD
CAWA45040AMedicare PIN