Provider Demographics
NPI:1326057894
Name:BRYANT, PHILLIP (DO)
Entity Type:Individual
Prefix:
First Name:PHILLIP
Middle Name:
Last Name:BRYANT
Suffix:
Gender:M
Credentials:DO
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:PO BOX 1475
Mailing Address - Street 2:
Mailing Address - City:DES MOINES
Mailing Address - State:IA
Mailing Address - Zip Code:50305-1475
Mailing Address - Country:US
Mailing Address - Phone:515-961-8448
Mailing Address - Fax:515-643-9100
Practice Address - Street 1:307 E SCENIC VALLEY AVE
Practice Address - Street 2:
Practice Address - City:INDIANOLA
Practice Address - State:IA
Practice Address - Zip Code:50125
Practice Address - Country:US
Practice Address - Phone:515-961-8448
Practice Address - Fax:515-643-9100
Is Sole Proprietor?:No
Enumeration Date:2006-08-05
Last Update Date:2018-06-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IA01818207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
IA2194878Medicaid
IA18292Medicare ID - Type Unspecified
IA2194878Medicaid