Provider Demographics
NPI:1790785384
Name:BRYANT, EDWARD GEORGE IV (OD)
Entity Type:Individual
Prefix:DR
First Name:EDWARD
Middle Name:GEORGE
Last Name:BRYANT
Suffix:IV
Gender:M
Credentials:OD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1284 DRYDEN ROAD
Mailing Address - Street 2:
Mailing Address - City:ITHACA
Mailing Address - State:NY
Mailing Address - Zip Code:14850-8795
Mailing Address - Country:US
Mailing Address - Phone:607-257-1066
Mailing Address - Fax:607-257-1378
Practice Address - Street 1:1284 DRYDEN ROAD
Practice Address - Street 2:
Practice Address - City:ITHACA
Practice Address - State:NY
Practice Address - Zip Code:14850-8795
Practice Address - Country:US
Practice Address - Phone:607-257-1066
Practice Address - Fax:607-257-1378
Is Sole Proprietor?:No
Enumeration Date:2005-07-26
Last Update Date:2019-04-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NYTUV006637152W00000X
PAOEG000430152W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes152W00000XEye and Vision Services ProvidersOptometrist
Provider Identifiers
StateIdentifier IDID TypeIssuer
NYU-77253Medicare UPIN
NYDD5433Medicare ID - Type Unspecified