Provider Demographics
NPI:1639115900
Name:TSAO, BRYAN E (MD)
Entity Type:Individual
Prefix:
First Name:BRYAN
Middle Name:E
Last Name:TSAO
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 1:11175 CAMPUS STREET
Mailing Address - Street 2:CP 11108
Mailing Address - City:LOMA LINDA
Mailing Address - State:CA
Mailing Address - Zip Code:92354
Mailing Address - Country:US
Mailing Address - Phone:909-558-4907
Mailing Address - Fax:909-478-0207
Practice Address - Street 1:11175 CAMPUS STREET
Practice Address - Street 2:CP 11108
Practice Address - City:LOMA LINDA
Practice Address - State:CA
Practice Address - Zip Code:92354
Practice Address - Country:US
Practice Address - Phone:909-558-4907
Practice Address - Fax:909-478-0207
Is Sole Proprietor?:No
Enumeration Date:2006-06-22
Last Update Date:2007-08-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OH350794552084N0400X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2084N0400XAllopathic & Osteopathic PhysiciansPsychiatry & NeurologyNeurology
Provider Identifiers
StateIdentifier IDID TypeIssuer
OH2265365Medicaid
OH2265365Medicaid