Provider Demographics
NPI:1174508147
Name:TOWNSEND, BRYAN LEE (MD)
Entity Type:Individual
Prefix:
First Name:BRYAN
Middle Name:LEE
Last Name:TOWNSEND
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 1:8044 SHOAL CREEK BLVD
Mailing Address - Street 2:
Mailing Address - City:AUSTIN
Mailing Address - State:TX
Mailing Address - Zip Code:78757-8039
Mailing Address - Country:US
Mailing Address - Phone:512-459-1269
Mailing Address - Fax:512-459-1404
Practice Address - Street 1:8044 SHOAL CREEK BLVD
Practice Address - Street 2:
Practice Address - City:AUSTIN
Practice Address - State:TX
Practice Address - Zip Code:78757-8039
Practice Address - Country:US
Practice Address - Phone:512-459-1269
Practice Address - Fax:512-459-1404
Is Sole Proprietor?:Yes
Enumeration Date:2005-12-13
Last Update Date:2017-08-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TXJ4566207N00000X, 207NS0135X, 207ND0101X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207ND0101XAllopathic & Osteopathic PhysiciansDermatologyMOHS-Micrographic Surgery
No207N00000XAllopathic & Osteopathic PhysiciansDermatology
No207NS0135XAllopathic & Osteopathic PhysiciansDermatologyProcedural Dermatology
Provider Identifiers
StateIdentifier IDID TypeIssuer
TX00087DMedicare ID - Type Unspecified
G62702Medicare UPIN
TX290367OtherAETNA
TX4162702OtherBLUE LINK
TX00078CHOtherBCBC
G62702Medicare UPIN
TX070012811OtherRR MDC