Provider Demographics
NPI:1639525231
Name:BRYAN, IAN LUKE (MD)
Entity Type:Individual
Prefix:DR
First Name:IAN
Middle Name:LUKE
Last Name:BRYAN
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:PO BOX 184
Mailing Address - Street 2:
Mailing Address - City:EDENTON
Mailing Address - State:NC
Mailing Address - Zip Code:27932-0184
Mailing Address - Country:US
Mailing Address - Phone:252-484-9024
Mailing Address - Fax:252-404-8424
Practice Address - Street 1:18 OLD FISH HATCHERY RD
Practice Address - Street 2:
Practice Address - City:EDENTON
Practice Address - State:NC
Practice Address - Zip Code:27932-1640
Practice Address - Country:US
Practice Address - Phone:252-484-9024
Practice Address - Fax:252-404-8424
Is Sole Proprietor?:No
Enumeration Date:2016-05-12
Last Update Date:2022-07-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NC2019-01984208000000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208000000XAllopathic & Osteopathic PhysiciansPediatrics