Provider Demographics
NPI:1417945478
Name:BLAIR, BRYAN M (MD)
Entity Type:Individual
Prefix:DR
First Name:BRYAN
Middle Name:M
Last Name:BLAIR
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 1:6400 WESTWIND WAY
Mailing Address - Street 2:
Mailing Address - City:CRESTWOOD
Mailing Address - State:KY
Mailing Address - Zip Code:40014-6773
Mailing Address - Country:US
Mailing Address - Phone:502-243-2227
Mailing Address - Fax:502-243-2237
Practice Address - Street 1:6400 WESTWIND WAY
Practice Address - Street 2:
Practice Address - City:CRESTWOOD
Practice Address - State:KY
Practice Address - Zip Code:40014-6773
Practice Address - Country:US
Practice Address - Phone:502-243-2227
Practice Address - Fax:502-243-2237
Is Sole Proprietor?:No
Enumeration Date:2005-10-12
Last Update Date:2021-06-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
KY35792207W00000X
KYBB6817196207W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207W00000XAllopathic & Osteopathic PhysiciansOphthalmology
Provider Identifiers
StateIdentifier IDID TypeIssuer
KYP00041810OtherMEDICARE RAILROAD
KY1177630003OtherMEDICARE DME MAC
IN300050706Medicaid
KY64066624Medicaid
H88993Medicare UPIN