Provider Demographics
NPI:1508975285
Name:BRYAN, LADONNA J (MD)
Entity Type:Individual
Prefix:DR
First Name:LADONNA
Middle Name:J
Last Name:BRYAN
Suffix:
Gender:F
Credentials:MD
Other - Prefix:
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Other - Last Name:
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Other - Credentials:
Mailing Address - Street 1:1600 W WALNUT ST
Mailing Address - Street 2:PASSAVANT SURGICAL ASSOCIATES
Mailing Address - City:JACKSONVILLE
Mailing Address - State:IL
Mailing Address - Zip Code:62650-1136
Mailing Address - Country:US
Mailing Address - Phone:217-479-5821
Mailing Address - Fax:217-243-7406
Practice Address - Street 1:1600 W WALNUT ST
Practice Address - Street 2:PASSAVANT SURGICAL ASSOCIATES
Practice Address - City:JACKSONVILLE
Practice Address - State:IL
Practice Address - Zip Code:62650-1136
Practice Address - Country:US
Practice Address - Phone:217-479-5821
Practice Address - Fax:217-243-7406
Is Sole Proprietor?:No
Enumeration Date:2006-08-29
Last Update Date:2023-03-07
Deactivation Date:
Deactivation Code:
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Provider Licenses
StateLicense IDTaxonomies
IL208600000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208600000XAllopathic & Osteopathic PhysiciansSurgery
Provider Identifiers
StateIdentifier IDID TypeIssuer
IL036111023 1Medicaid
IL036111023 2Medicaid
IL036111023 2Medicaid
IL214660 K08848Medicare ID - Type Unspecified
IL632920 K11290Medicare ID - Type Unspecified
IL036111023 1Medicaid