Provider Demographics
NPI:1700847050
Name:BRYAN, BRUCE JACKSON (MD)
Entity Type:Individual
Prefix:DR
First Name:BRUCE
Middle Name:JACKSON
Last Name:BRYAN
Suffix:
Gender:M
Credentials:MD
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Mailing Address - Street 1:PO BOX 2850
Mailing Address - Street 2:163 WHITE MOUNTAIN HWY SUITE D
Mailing Address - City:PINETOP
Mailing Address - State:AZ
Mailing Address - Zip Code:85935-2850
Mailing Address - Country:US
Mailing Address - Phone:928-367-1200
Mailing Address - Fax:928-367-1205
Practice Address - Street 1:163 W WHITE MOUNTAIN HWY
Practice Address - Street 2:SUITE D
Practice Address - City:PINETOP
Practice Address - State:AZ
Practice Address - Zip Code:85935-2850
Practice Address - Country:US
Practice Address - Phone:928-367-1200
Practice Address - Fax:928-367-1205
Is Sole Proprietor?:No
Enumeration Date:2006-03-28
Last Update Date:2007-08-24
Deactivation Date:
Deactivation Code:
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Provider Licenses
StateLicense IDTaxonomies
AZ20232208600000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208600000XAllopathic & Osteopathic PhysiciansSurgery