Provider Demographics
NPI:1558326454
Name:BRYAN, JAMES WITT IV (MD)
Entity Type:Individual
Prefix:DR
First Name:JAMES
Middle Name:WITT
Last Name:BRYAN
Suffix:IV
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 1:1090 ARNOLD DR
Mailing Address - Street 2:
Mailing Address - City:LITTLE ROCK AIR FORCE BASE
Mailing Address - State:AR
Mailing Address - Zip Code:72099-4933
Mailing Address - Country:US
Mailing Address - Phone:501-987-7319
Mailing Address - Fax:501-987-1464
Practice Address - Street 1:1090 ARNOLD DR
Practice Address - Street 2:19 AMDS/SGPF
Practice Address - City:LITTLE ROCK AIR FORCE BASE
Practice Address - State:AR
Practice Address - Zip Code:72099-4933
Practice Address - Country:US
Practice Address - Phone:501-987-7319
Practice Address - Fax:501-987-1464
Is Sole Proprietor?:Yes
Enumeration Date:2006-04-20
Last Update Date:2024-03-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
ARC-7904207QS0010X, 207Q00000X
ARC7904207Q00000X, 207QS0010X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207QS0010XAllopathic & Osteopathic PhysiciansFamily MedicineSports Medicine
No207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
AR121472001Medicaid
AR121472001Medicaid
55017Medicare ID - Type Unspecified
AR550176835Medicare PIN