Provider Demographics
NPI:1467449868
Name:BRYANT, MARK (OD)
Entity Type:Individual
Prefix:DR
First Name:MARK
Middle Name:
Last Name:BRYANT
Suffix:
Gender:M
Credentials:OD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
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Other - Credentials:
Mailing Address - Street 1:4998 SHADY CREST AVE NW
Mailing Address - Street 2:
Mailing Address - City:MASSILLON
Mailing Address - State:OH
Mailing Address - Zip Code:44646-9554
Mailing Address - Country:US
Mailing Address - Phone:330-479-9750
Mailing Address - Fax:330-479-9752
Practice Address - Street 1:4004 TUSCARAWAS ST W
Practice Address - Street 2:
Practice Address - City:CANTON
Practice Address - State:OH
Practice Address - Zip Code:44708-5503
Practice Address - Country:US
Practice Address - Phone:330-479-9750
Practice Address - Fax:330-479-9752
Is Sole Proprietor?:No
Enumeration Date:2005-09-30
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OH4727152W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes152W00000XEye and Vision Services ProvidersOptometrist
Provider Identifiers
StateIdentifier IDID TypeIssuer
OHU64702Medicare UPIN