Provider Demographics
NPI:1508860099
Name:BRYANT, MARK L (OD)
Entity Type:Individual
Prefix:
First Name:MARK
Middle Name:L
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 1:216 CORDER RD
Mailing Address - Street 2:
Mailing Address - City:WARNER ROBINS
Mailing Address - State:GA
Mailing Address - Zip Code:31088-3604
Mailing Address - Country:US
Mailing Address - Phone:478-923-5872
Mailing Address - Fax:478-922-9020
Practice Address - Street 1:1011 N 4TH ST
Practice Address - Street 2:
Practice Address - City:CORDELE
Practice Address - State:GA
Practice Address - Zip Code:31015
Practice Address - Country:US
Practice Address - Phone:229-273-0435
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2005-06-13
Last Update Date:2018-06-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GA001209152WX0102X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes152WX0102XEye and Vision Services ProvidersOptometristOccupational Vision
Provider Identifiers
StateIdentifier IDID TypeIssuer
GA483070OtherAETNA
GA410048938OtherRR MEDICARE
GA00415269AMedicaid
GA538385OtherBCBS OF GA
GA538385OtherBCBS OF GA