Provider Demographics
NPI:1639169436
Name:MASSENBURG, BRYAN EDWARD (MD)
Entity Type:Individual
Prefix:
First Name:BRYAN
Middle Name:EDWARD
Last Name:MASSENBURG
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 1:5012 S US HIGHWAY 75 STE 300
Mailing Address - Street 2:ATTN BILLING
Mailing Address - City:DENISON
Mailing Address - State:TX
Mailing Address - Zip Code:75020-4589
Mailing Address - Country:US
Mailing Address - Phone:903-416-7544
Mailing Address - Fax:
Practice Address - Street 1:3126 W FM 120
Practice Address - Street 2:
Practice Address - City:DENISON
Practice Address - State:TX
Practice Address - Zip Code:75020-1249
Practice Address - Country:US
Practice Address - Phone:903-416-7544
Practice Address - Fax:903-416-7545
Is Sole Proprietor?:No
Enumeration Date:2005-10-24
Last Update Date:2018-01-26
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TXL0862207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
TX102612204Medicaid
TX102612204Medicaid
TX8L11847Medicare PIN