Provider Demographics
NPI:1639170491
Name:STEPHENS, BRYON J (MD)
Entity Type:Individual
Prefix:
First Name:BRYON
Middle Name:J
Last Name:STEPHENS
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 1:6920 POINTE INVERNESS WAY STE 200
Mailing Address - Street 2:
Mailing Address - City:FORT WAYNE
Mailing Address - State:IN
Mailing Address - Zip Code:46804-7934
Mailing Address - Country:US
Mailing Address - Phone:260-479-3514
Mailing Address - Fax:260-479-3520
Practice Address - Street 1:7910 W JEFFERSON BLVD
Practice Address - Street 2:SUITE 112
Practice Address - City:FORT WAYNE
Practice Address - State:IN
Practice Address - Zip Code:46804-4159
Practice Address - Country:US
Practice Address - Phone:260-969-7121
Practice Address - Fax:260-436-4292
Is Sole Proprietor?:No
Enumeration Date:2005-08-02
Last Update Date:2020-09-30
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IN01040106A208600000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208600000XAllopathic & Osteopathic PhysiciansSurgery
Provider Identifiers
StateIdentifier IDID TypeIssuer
OH0998112Medicaid
IN100082280Medicaid
MI103410227Medicaid
INP00919721OtherRAILROAD MEDICARE
INA76485Medicare UPIN
MI103410227Medicaid
MI103410227Medicaid
IN100082280Medicaid
IN020026957Medicare PIN
IN260100KMedicare PIN