Provider Demographics
NPI:1598749236
Name:ANDERSON, BRYAN K (MD)
Entity Type:Individual
Prefix:MR
First Name:BRYAN
Middle Name:K
Last Name:ANDERSON
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 1:1565 EBENEZER ROAD
Mailing Address - Street 2:
Mailing Address - City:ROCK HILL
Mailing Address - State:SC
Mailing Address - Zip Code:29732
Mailing Address - Country:US
Mailing Address - Phone:803-328-0168
Mailing Address - Fax:803-325-8473
Practice Address - Street 1:1565 EBENEZER ROAD
Practice Address - Street 2:
Practice Address - City:ROCK HILL
Practice Address - State:SC
Practice Address - Zip Code:29732
Practice Address - Country:US
Practice Address - Phone:803-328-0168
Practice Address - Fax:803-325-8473
Is Sole Proprietor?:No
Enumeration Date:2005-12-06
Last Update Date:2007-10-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
SC13734207W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207W00000XAllopathic & Osteopathic PhysiciansOphthalmology
Provider Identifiers
StateIdentifier IDID TypeIssuer
SC137346Medicaid
C60882Medicare UPIN
SC2041Medicare ID - Type Unspecified