Provider Demographics
NPI:1578591616
Name:BRYAN, ROBERT NICK (MD)
Entity Type:Individual
Prefix:
First Name:ROBERT
Middle Name:NICK
Last Name:BRYAN
Suffix:
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 1:1701 TRINITY STREET
Mailing Address - Street 2:DELL MEDICAL SCHOOL
Mailing Address - City:AUSTIN
Mailing Address - State:TX
Mailing Address - Zip Code:78712-1845
Mailing Address - Country:US
Mailing Address - Phone:512-495-5063
Mailing Address - Fax:
Practice Address - Street 1:1701 TRINITY STREET
Practice Address - Street 2:DELL MEDICAL SCHOOL
Practice Address - City:AUSTIN
Practice Address - State:TX
Practice Address - Zip Code:78712-1845
Practice Address - Country:US
Practice Address - Phone:512-495-5063
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2006-06-29
Last Update Date:2017-04-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
PAMD0689812085N0700X
PAMD068981L2085N0700X, 2085R0202X
TXD59252085R0202X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2085R0202XAllopathic & Osteopathic PhysiciansRadiologyDiagnostic Radiology
No2085N0700XAllopathic & Osteopathic PhysiciansRadiologyNeuroradiology
Provider Identifiers
StateIdentifier IDID TypeIssuer
PA0016330360004Medicaid
E82354Medicare UPIN
PA0016330360004Medicaid