Provider Demographics
NPI:1669484333
Name:MAYOL, BRYAN R (MD)
Entity Type:Individual
Prefix:
First Name:BRYAN
Middle Name:R
Last Name:MAYOL
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 1:250 N SHADELAND AVE
Mailing Address - Street 2:STE 130
Mailing Address - City:INDIANAPOLIS
Mailing Address - State:IN
Mailing Address - Zip Code:46219-4959
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:13100 136TH STREET
Practice Address - Street 2:SUITE 2000
Practice Address - City:FISHERS
Practice Address - State:IN
Practice Address - Zip Code:46037-9440
Practice Address - Country:US
Practice Address - Phone:317-688-5980
Practice Address - Fax:317-688-3222
Is Sole Proprietor?:No
Enumeration Date:2006-08-12
Last Update Date:2014-11-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IN01049047207Q00000X
IN01069552A207Q00000X, 207QS0010X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207QS0010XAllopathic & Osteopathic PhysiciansFamily MedicineSports Medicine
No207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
IN200265700Medicaid
INH20655Medicare UPIN
IN200265700Medicaid
IN068010004Medicare PIN
INM400054502Medicare PIN
INP01141658Medicare PIN
ININ1546002Medicare PIN
INP01362647Medicare PIN