Provider Demographics
NPI:1346239126
Name:HOLLAND, BRYAN R (MD)
Entity Type:Individual
Prefix:
First Name:BRYAN
Middle Name:R
Last Name:HOLLAND
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 1:43 ENTERPRISE DR
Mailing Address - Street 2:
Mailing Address - City:BRISTOL
Mailing Address - State:CT
Mailing Address - Zip Code:06010-7457
Mailing Address - Country:US
Mailing Address - Phone:860-589-5230
Mailing Address - Fax:860-589-5297
Practice Address - Street 1:43 ENTERPRISE DR
Practice Address - Street 2:
Practice Address - City:BRISTOL
Practice Address - State:CT
Practice Address - Zip Code:06010-7457
Practice Address - Country:US
Practice Address - Phone:860-589-5230
Practice Address - Fax:860-589-5297
Is Sole Proprietor?:No
Enumeration Date:2005-10-14
Last Update Date:2015-01-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CT041661208000000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208000000XAllopathic & Osteopathic PhysiciansPediatrics
Provider Identifiers
StateIdentifier IDID TypeIssuer
CT001416610Medicaid
CT001416610Medicaid
CT001416610Medicaid