Provider Demographics
NPI:1356443196
Name:BRYAN, MICHAEL GRANT (MD)
Entity Type:Individual
Prefix:DR
First Name:MICHAEL
Middle Name:GRANT
Last Name:BRYAN
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:PO BOX 12060
Mailing Address - Street 2:
Mailing Address - City:LAS VEGAS
Mailing Address - State:NV
Mailing Address - Zip Code:89112-0060
Mailing Address - Country:US
Mailing Address - Phone:702-360-2100
Mailing Address - Fax:909-557-1924
Practice Address - Street 1:4488 S PECOS RD
Practice Address - Street 2:
Practice Address - City:LAS VEGAS
Practice Address - State:NV
Practice Address - Zip Code:89121-5030
Practice Address - Country:US
Practice Address - Phone:702-436-1001
Practice Address - Fax:702-436-7999
Is Sole Proprietor?:No
Enumeration Date:2006-09-02
Last Update Date:2013-01-31
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NV11335207N00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207N00000XAllopathic & Osteopathic PhysiciansDermatology
Provider Identifiers
StateIdentifier IDID TypeIssuer
NVP01115811OtherRR MEDICARE
NVP01115811OtherRR MEDICARE
NVGL341ZMedicare PIN