Provider Demographics
NPI:1700848371
Name:BRYANT, SULLIVAN R (DO)
Entity Type:Individual
Prefix:
First Name:SULLIVAN
Middle Name:R
Last Name:BRYANT
Suffix:
Gender:M
Credentials:DO
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:3534 N HAMPTON RD
Mailing Address - Street 2:
Mailing Address - City:DALLAS
Mailing Address - State:TX
Mailing Address - Zip Code:75212
Mailing Address - Country:US
Mailing Address - Phone:214-631-5234
Mailing Address - Fax:214-631-7801
Practice Address - Street 1:3534 N HAMPTON RD
Practice Address - Street 2:
Practice Address - City:DALLAS
Practice Address - State:TX
Practice Address - Zip Code:75212
Practice Address - Country:US
Practice Address - Phone:214-631-5234
Practice Address - Fax:214-631-7801
Is Sole Proprietor?:No
Enumeration Date:2006-04-06
Last Update Date:2011-09-26
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TXE2992207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
TX083894801Medicaid
D75103Medicare UPIN
TX083894801Medicaid