Provider Demographics
NPI:1710971320
Name:UPDEGRAFF, BRYAN ROBERT (MD)
Entity Type:Individual
Prefix:
First Name:BRYAN
Middle Name:ROBERT
Last Name:UPDEGRAFF
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 1:14666 N DEL WEBB BLVD
Mailing Address - Street 2:
Mailing Address - City:SUN CITY
Mailing Address - State:AZ
Mailing Address - Zip Code:85351-2137
Mailing Address - Country:US
Mailing Address - Phone:623-933-3107
Mailing Address - Fax:623-972-1418
Practice Address - Street 1:14666 N DEL WEBB BLVD
Practice Address - Street 2:
Practice Address - City:SUN CITY
Practice Address - State:AZ
Practice Address - Zip Code:85351-2137
Practice Address - Country:US
Practice Address - Phone:623-933-3107
Practice Address - Fax:623-972-1418
Is Sole Proprietor?:No
Enumeration Date:2005-09-09
Last Update Date:2024-01-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AZ10896207NI0002X, 207NP0225X, 207NS0135X, 207N00000X, 207K00000X, 207KA0200X, 207ND0101X, 207ND0900X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207N00000XAllopathic & Osteopathic PhysiciansDermatology
No207NI0002XAllopathic & Osteopathic PhysiciansDermatologyClinical & Laboratory Dermatological Immunology
No207NP0225XAllopathic & Osteopathic PhysiciansDermatologyPediatric Dermatology
No207NS0135XAllopathic & Osteopathic PhysiciansDermatologyProcedural Dermatology
No207K00000XAllopathic & Osteopathic PhysiciansAllergy & Immunology
No207KA0200XAllopathic & Osteopathic PhysiciansAllergy & ImmunologyAllergy
No207ND0101XAllopathic & Osteopathic PhysiciansDermatologyMOHS-Micrographic Surgery
No207ND0900XAllopathic & Osteopathic PhysiciansDermatologyDermatopathology
Provider Identifiers
StateIdentifier IDID TypeIssuer
AZZ126220Medicare PIN
AZD00471Medicare UPIN
AZZ126219Medicare PIN