Provider Demographics
NPI:1447396890
Name:BRYAN, LIONEL (MD)
Entity Type:Individual
Prefix:
First Name:LIONEL
Middle Name:
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 1:1007 MARY ST
Mailing Address - Street 2:
Mailing Address - City:WAYCROSS
Mailing Address - State:GA
Mailing Address - Zip Code:31503-3823
Mailing Address - Country:US
Mailing Address - Phone:912-449-7100
Mailing Address - Fax:
Practice Address - Street 1:1007 MARY ST
Practice Address - Street 2:
Practice Address - City:WAYCROSS
Practice Address - State:GA
Practice Address - Zip Code:31503-3823
Practice Address - Country:US
Practice Address - Phone:912-449-7100
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2007-01-30
Last Update Date:2012-04-30
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GA0227252084P0800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2084P0800XAllopathic & Osteopathic PhysiciansPsychiatry & NeurologyPsychiatry
Provider Identifiers
StateIdentifier IDID TypeIssuer
GA003122616AMedicaid
GAGRP3993Medicare PIN
GA26BDHVSMedicare ID - Type Unspecified
GA003122616AMedicaid