Provider Demographics
NPI:1255314415
Name:BRYAN, ANNE B (MD)
Entity Type:Individual
Prefix:MRS
First Name:ANNE
Middle Name:B
Last Name:BRYAN
Suffix:
Gender:F
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:9007 ELLERBE RD
Mailing Address - Street 2:
Mailing Address - City:SHREVEPORT
Mailing Address - State:LA
Mailing Address - Zip Code:71106-6724
Mailing Address - Country:US
Mailing Address - Phone:318-222-3278
Mailing Address - Fax:318-424-3155
Practice Address - Street 1:9007 ELLERBE RD
Practice Address - Street 2:
Practice Address - City:SHREVEPORT
Practice Address - State:LA
Practice Address - Zip Code:71106-6724
Practice Address - Country:US
Practice Address - Phone:318-222-3278
Practice Address - Fax:318-424-3155
Is Sole Proprietor?:No
Enumeration Date:2005-11-22
Last Update Date:2012-03-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
LAG22563207N00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207N00000XAllopathic & Osteopathic PhysiciansDermatology
Provider Identifiers
StateIdentifier IDID TypeIssuer
LA1490504Medicaid
LA5ES10Medicare ID - Type Unspecified
G92801Medicare UPIN