Provider Demographics
NPI:1497768170
Name:BRYAN, THOMAS BENEDICT (MD)
Entity Type:Individual
Prefix:
First Name:THOMAS
Middle Name:BENEDICT
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 1:3351 M ST
Mailing Address - Street 2:STE 120
Mailing Address - City:MERCED
Mailing Address - State:CA
Mailing Address - Zip Code:95348
Mailing Address - Country:US
Mailing Address - Phone:209-383-5999
Mailing Address - Fax:209-383-6888
Practice Address - Street 1:3351 M STREET
Practice Address - Street 2:STE 120
Practice Address - City:MERCED
Practice Address - State:CA
Practice Address - Zip Code:95348
Practice Address - Country:US
Practice Address - Phone:209-383-5999
Practice Address - Fax:209-383-6888
Is Sole Proprietor?:Yes
Enumeration Date:2006-08-14
Last Update Date:2014-02-25
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAA3006902084P2900X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2084P2900XAllopathic & Osteopathic PhysiciansPsychiatry & NeurologyPain Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
CA00A300690Medicaid
CA00A300690Medicaid