Provider Demographics
NPI:1518906676
Name:BRYANT, MARVIN LAMAR JR (MD)
Entity Type:Individual
Prefix:
First Name:MARVIN
Middle Name:LAMAR
Last Name:BRYANT
Suffix:JR
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:M.
Other - Middle Name:LAMAR
Other - Last Name:BRYANT
Other - Suffix:JR
Other - Last Name Type:Other Name
Other - Credentials:MD
Mailing Address - Street 1:700 NE 87TH AVE
Mailing Address - Street 2:
Mailing Address - City:VANCOUVER
Mailing Address - State:WA
Mailing Address - Zip Code:98664-1913
Mailing Address - Country:US
Mailing Address - Phone:360-882-2778
Mailing Address - Fax:360-604-1737
Practice Address - Street 1:2525 NE 139TH ST
Practice Address - Street 2:
Practice Address - City:VANCOUVER
Practice Address - State:WA
Practice Address - Zip Code:98686-2719
Practice Address - Country:US
Practice Address - Phone:360-882-2778
Practice Address - Fax:360-604-1737
Is Sole Proprietor?:No
Enumeration Date:2006-06-05
Last Update Date:2016-07-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WAMD00044491207RG0100X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207RG0100XAllopathic & Osteopathic PhysiciansInternal MedicineGastroenterology
Provider Identifiers
StateIdentifier IDID TypeIssuer
WA8431322Medicaid
WA8431322Medicaid