Provider Demographics
NPI:1609931260
Name:O'BRYAN, GREGORY D (OD)
Entity Type:Individual
Prefix:
First Name:GREGORY
Middle Name:D
Last Name:O'BRYAN
Suffix:
Gender:M
Credentials:OD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:3120 KARNES RD
Mailing Address - Street 2:SUITE A
Mailing Address - City:SAINT JOSEPH
Mailing Address - State:MO
Mailing Address - Zip Code:64506-1319
Mailing Address - Country:US
Mailing Address - Phone:816-364-5800
Mailing Address - Fax:816-364-5806
Practice Address - Street 1:3120 KARNES RD
Practice Address - Street 2:SUITE A
Practice Address - City:SAINT JOSEPH
Practice Address - State:MO
Practice Address - Zip Code:64506-1319
Practice Address - Country:US
Practice Address - Phone:816-364-5800
Practice Address - Fax:816-364-5806
Is Sole Proprietor?:Yes
Enumeration Date:2006-12-26
Last Update Date:2009-10-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MO2002017826152W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes152W00000XEye and Vision Services ProvidersOptometrist
Provider Identifiers
StateIdentifier IDID TypeIssuer
Q22C040Medicare PIN
MOU91965Medicare UPIN