Provider Demographics
NPI:1497794010
Name:THOMAS, BRYON WESLEY (MD)
Entity Type:Individual
Prefix:
First Name:BRYON
Middle Name:WESLEY
Last Name:THOMAS
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 1:303 S MAIN ST
Mailing Address - Street 2:SUITE 212
Mailing Address - City:MISHAWAKA
Mailing Address - State:IN
Mailing Address - Zip Code:46544-2189
Mailing Address - Country:US
Mailing Address - Phone:574-254-0800
Mailing Address - Fax:574-254-0812
Practice Address - Street 1:303 S MAIN ST
Practice Address - Street 2:SUITE 212
Practice Address - City:MISHAWAKA
Practice Address - State:IN
Practice Address - Zip Code:46544-2189
Practice Address - Country:US
Practice Address - Phone:574-254-0800
Practice Address - Fax:574-254-0812
Is Sole Proprietor?:No
Enumeration Date:2006-06-06
Last Update Date:2012-08-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IN01052749207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
IN200290600AMedicaid
INH20907Medicare UPIN
IN200290600AMedicaid
IN187670BMedicare PIN