Provider Demographics
NPI:1568764975
Name:BRYAN N ANGLE MD PA
Entity Type:Organization
Organization Name:BRYAN N ANGLE MD PA
Other - Org Name:ANGELO RETINA ASSOCIATES
Other - Org Type:Doing Business As
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:DR
Authorized Official - First Name:BRYAN
Authorized Official - Middle Name:N
Authorized Official - Last Name:ANGLE
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:325-942-9300
Mailing Address - Street 1:303 W HARRIS AVE
Mailing Address - Street 2:SUITE 3
Mailing Address - City:SAN ANGELO
Mailing Address - State:TX
Mailing Address - Zip Code:76903-6377
Mailing Address - Country:US
Mailing Address - Phone:325-942-9300
Mailing Address - Fax:325-942-9333
Practice Address - Street 1:303 W HARRIS AVE
Practice Address - Street 2:SUITE 3
Practice Address - City:SAN ANGELO
Practice Address - State:TX
Practice Address - Zip Code:76903-6377
Practice Address - Country:US
Practice Address - Phone:325-942-9300
Practice Address - Fax:325-942-9333
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2010-11-18
Last Update Date:2012-10-30
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TXJ1844207W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207W00000XAllopathic & Osteopathic PhysiciansOphthalmologyGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
TX100331104Medicaid
8K6102OtherMEDICARE PTAN