Provider Demographics
NPI:1427363449
Name:BRYANT, JUSTIN R (DO, MBA)
Entity Type:Individual
Prefix:DR
First Name:JUSTIN
Middle Name:R
Last Name:BRYANT
Suffix:
Gender:M
Credentials:DO, MBA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:11109 PARKVIEW PLAZA DRIVE
Mailing Address - Street 2:MAILBOX 117
Mailing Address - City:FORT WAYNE
Mailing Address - State:IN
Mailing Address - Zip Code:46845
Mailing Address - Country:US
Mailing Address - Phone:260-266-8210
Mailing Address - Fax:
Practice Address - Street 1:11141 PARKVIEW PLAZA DR STE 300
Practice Address - Street 2:
Practice Address - City:FORT WAYNE
Practice Address - State:IN
Practice Address - Zip Code:46845-1715
Practice Address - Country:US
Practice Address - Phone:260-425-6960
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2010-08-13
Last Update Date:2022-10-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
DCDO034726208200000X
WI71983208200000X
IN02004908A2086S0122X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2086S0122XAllopathic & Osteopathic PhysiciansSurgeryPlastic and Reconstructive Surgery
No208200000XAllopathic & Osteopathic PhysiciansPlastic Surgery
Provider Identifiers
StateIdentifier IDID TypeIssuer
WI1427363449Medicaid