Provider Demographics
NPI:1528035888
Name:BRYAN, GREGORY W (DPM)
Entity Type:Individual
Prefix:
First Name:GREGORY
Middle Name:W
Last Name:BRYAN
Suffix:
Gender:M
Credentials:DPM
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:385 BERT KOUNS
Mailing Address - Street 2:BLDG. 200
Mailing Address - City:SHREVEPORT
Mailing Address - State:LA
Mailing Address - Zip Code:71106-8158
Mailing Address - Country:US
Mailing Address - Phone:318-687-8447
Mailing Address - Fax:318-687-9950
Practice Address - Street 1:385 BERT KOUNS
Practice Address - Street 2:BLDG. 200
Practice Address - City:SHREVEPORT
Practice Address - State:LA
Practice Address - Zip Code:71106-8158
Practice Address - Country:US
Practice Address - Phone:318-687-8447
Practice Address - Fax:318-687-9950
Is Sole Proprietor?:No
Enumeration Date:2006-03-07
Last Update Date:2011-07-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
LAPD067R213ES0131X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes213ES0131XPodiatric Medicine & Surgery Service ProvidersPodiatristFoot Surgery
Provider Identifiers
StateIdentifier IDID TypeIssuer
LA1382850Medicaid
T19680Medicare UPIN
56019Medicare PIN
LA1382850Medicaid