Provider Demographics
NPI:1598021677
Name:STANISTREET, BRYAN J (MD)
Entity Type:Individual
Prefix:
First Name:BRYAN
Middle Name:J
Last Name:STANISTREET
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 1:3101 W RIDGE RD BLDG C
Mailing Address - Street 2:
Mailing Address - City:ROCHESTER
Mailing Address - State:NY
Mailing Address - Zip Code:14626-3249
Mailing Address - Country:US
Mailing Address - Phone:585-225-1700
Mailing Address - Fax:585-225-1439
Practice Address - Street 1:3101 W RIDGE RD BLDG C
Practice Address - Street 2:
Practice Address - City:ROCHESTER
Practice Address - State:NY
Practice Address - Zip Code:14626
Practice Address - Country:US
Practice Address - Phone:585-225-1700
Practice Address - Fax:585-225-1439
Is Sole Proprietor?:No
Enumeration Date:2012-04-03
Last Update Date:2020-09-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY276576207R00000X, 208000000X
NC2018-02306208M00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208M00000XAllopathic & Osteopathic PhysiciansHospitalist
Yes207R00000XAllopathic & Osteopathic PhysiciansInternal Medicine
No208000000XAllopathic & Osteopathic PhysiciansPediatrics
Provider Identifiers
StateIdentifier IDID TypeIssuer
NY04450506Medicaid
NYJ400307646Medicare PIN