Provider Demographics
NPI:1336284595
Name:CAIN, BRYAN
Entity Type:Individual
Prefix:DR
First Name:BRYAN
Middle Name:
Last Name:CAIN
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:5101 SW LEE BLVD
Mailing Address - Street 2:
Mailing Address - City:LAWTON
Mailing Address - State:OK
Mailing Address - Zip Code:73505-8317
Mailing Address - Country:US
Mailing Address - Phone:580-357-8720
Mailing Address - Fax:580-357-8759
Practice Address - Street 1:5101 SW LEE BLVD
Practice Address - Street 2:
Practice Address - City:LAWTON
Practice Address - State:OK
Practice Address - Zip Code:73505-8317
Practice Address - Country:US
Practice Address - Phone:580-357-8720
Practice Address - Fax:580-357-8759
Is Sole Proprietor?:Yes
Enumeration Date:2007-02-21
Last Update Date:2008-03-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OK153213E00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes213E00000XPodiatric Medicine & Surgery Service ProvidersPodiatrist
Provider Identifiers
StateIdentifier IDID TypeIssuer
731182936001OtherBCBS
0725380001Medicare NSC
731182936001OtherBCBS