Provider Demographics
NPI:1164425245
Name:BRYANT, TIMOTHY GORDON (MD)
Entity Type:Individual
Prefix:DR
First Name:TIMOTHY
Middle Name:GORDON
Last Name:BRYANT
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 1:1700 N ROSE AVE
Mailing Address - Street 2:STE 430
Mailing Address - City:OXNARD
Mailing Address - State:CA
Mailing Address - Zip Code:93030-7657
Mailing Address - Country:US
Mailing Address - Phone:805-485-8722
Mailing Address - Fax:805-485-9311
Practice Address - Street 1:1700 N ROSE AVE
Practice Address - Street 2:STE 430
Practice Address - City:OXNARD
Practice Address - State:CA
Practice Address - Zip Code:93030-7657
Practice Address - Country:US
Practice Address - Phone:805-485-8722
Practice Address - Fax:805-485-9311
Is Sole Proprietor?:No
Enumeration Date:2005-05-23
Last Update Date:2012-03-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAG53185208600000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208600000XAllopathic & Osteopathic PhysiciansSurgery
Provider Identifiers
StateIdentifier IDID TypeIssuer
CA00G531850Medicaid
CAWG53185HMedicare ID - Type UnspecifiedMEDICARE
CA00G531850Medicaid