Provider Demographics
NPI:1588626774
Name:BRYANT, JOHNNY WAYNE (MD)
Entity Type:Individual
Prefix:
First Name:JOHNNY
Middle Name:WAYNE
Last Name:BRYANT
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 1:423 SOUTH 28TH ST
Mailing Address - Street 2:SUITE A
Mailing Address - City:PADUCAH
Mailing Address - State:KY
Mailing Address - Zip Code:42003-3865
Mailing Address - Country:US
Mailing Address - Phone:270-442-7181
Mailing Address - Fax:271-442-0113
Practice Address - Street 1:423 SOUTH 28TH ST
Practice Address - Street 2:SUITE A
Practice Address - City:PADUCAH
Practice Address - State:KY
Practice Address - Zip Code:42003-3865
Practice Address - Country:US
Practice Address - Phone:270-442-7181
Practice Address - Fax:271-442-0113
Is Sole Proprietor?:Yes
Enumeration Date:2006-04-04
Last Update Date:2012-06-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
KY35692207VG0400X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207VG0400XAllopathic & Osteopathic PhysiciansObstetrics & GynecologyGynecology
Provider Identifiers
StateIdentifier IDID TypeIssuer
KY64013931Medicaid
KY64013931Medicaid
0660501Medicare ID - Type Unspecified