Provider Demographics
NPI:1457455859
Name:BRYANT, MASON T (OD)
Entity Type:Individual
Prefix:
First Name:MASON
Middle Name:T
Last Name:BRYANT
Suffix:
Gender:M
Credentials:OD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:11103 WEST AVE
Mailing Address - Street 2:
Mailing Address - City:SAN ANTONIO
Mailing Address - State:TX
Mailing Address - Zip Code:78213
Mailing Address - Country:US
Mailing Address - Phone:210-524-6803
Mailing Address - Fax:210-524-6587
Practice Address - Street 1:2407 S COLLEGE AVE
Practice Address - Street 2:#300
Practice Address - City:FORT COLLINS
Practice Address - State:CO
Practice Address - Zip Code:80528
Practice Address - Country:US
Practice Address - Phone:970-484-3787
Practice Address - Fax:970-484-0133
Is Sole Proprietor?:No
Enumeration Date:2006-09-07
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CO2364152W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes152W00000XEye and Vision Services ProvidersOptometrist
Provider Identifiers
StateIdentifier IDID TypeIssuer
COU97172Medicare UPIN