Provider Demographics
NPI:1467416552
Name:BRYAN, JOHN HUGH (MD)
Entity Type:Individual
Prefix:
First Name:JOHN
Middle Name:HUGH
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 41208
Mailing Address - Street 2:
Mailing Address - City:FAYETTEVILLE
Mailing Address - State:NC
Mailing Address - Zip Code:28309-1208
Mailing Address - Country:US
Mailing Address - Phone:910-609-6691
Mailing Address - Fax:910-609-5398
Practice Address - Street 1:1638 OWEN DR
Practice Address - Street 2:
Practice Address - City:FAYETTEVILLE
Practice Address - State:NC
Practice Address - Zip Code:28304-3424
Practice Address - Country:US
Practice Address - Phone:910-609-6690
Practice Address - Fax:910-609-6313
Is Sole Proprietor?:Yes
Enumeration Date:2006-04-14
Last Update Date:2008-01-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NC163282085R0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2085R0001XAllopathic & Osteopathic PhysiciansRadiologyRadiation Oncology
Provider Identifiers
StateIdentifier IDID TypeIssuer
NC8919374Medicaid
NC205098Medicare PIN
NC8919374Medicaid