Provider Demographics
NPI:1790871127
Name:BRYANT, KEVIN M (DO)
Entity Type:Individual
Prefix:DR
First Name:KEVIN
Middle Name:M
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 1:2100 W COLORADO BLVD
Mailing Address - Street 2:
Mailing Address - City:DALLAS
Mailing Address - State:TX
Mailing Address - Zip Code:75211
Mailing Address - Country:US
Mailing Address - Phone:214-943-4631
Mailing Address - Fax:214-946-5334
Practice Address - Street 1:2100 W COLORADO BLVD
Practice Address - Street 2:
Practice Address - City:DALLAS
Practice Address - State:TX
Practice Address - Zip Code:75211
Practice Address - Country:US
Practice Address - Phone:214-943-4631
Practice Address - Fax:214-946-5334
Is Sole Proprietor?:Yes
Enumeration Date:2006-10-05
Last Update Date:2014-09-04
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TXK2425207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
TX113509704Medicaid
TX113509704Medicaid
TX8088N0Medicare PIN