Provider Demographics
NPI:1346334075
Name:CONKLIN, BRYAN RICHARD (MD PC)
Entity Type:Individual
Prefix:DR
First Name:BRYAN
Middle Name:RICHARD
Last Name:CONKLIN
Suffix:
Gender:M
Credentials:MD PC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2011 FOURTH STREET
Mailing Address - Street 2:
Mailing Address - City:LA GRANDE
Mailing Address - State:OR
Mailing Address - Zip Code:97850
Mailing Address - Country:US
Mailing Address - Phone:541-963-4139
Mailing Address - Fax:541-963-4412
Practice Address - Street 1:2011 FOURTH STREET
Practice Address - Street 2:
Practice Address - City:LA GRANDE
Practice Address - State:OR
Practice Address - Zip Code:97850-1200
Practice Address - Country:US
Practice Address - Phone:541-963-4139
Practice Address - Fax:541-963-4412
Is Sole Proprietor?:No
Enumeration Date:2006-10-03
Last Update Date:2012-04-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
ORMD23049207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
OR228792Medicaid
117125Medicare ID - Type Unspecified
H40841Medicare UPIN