Provider Demographics
NPI:1790984540
Name:MCCONNELL, BRYAN T (DO)
Entity Type:Individual
Prefix:DR
First Name:BRYAN
Middle Name:T
Last Name:MCCONNELL
Suffix:
Gender:M
Credentials:DO
Other - Prefix:
Other - First Name:
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Other - Last Name:
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Other - Credentials:
Mailing Address - Street 1:3280 S CAMINO DEL SOL STE 124
Mailing Address - Street 2:
Mailing Address - City:GREEN VALLEY
Mailing Address - State:AZ
Mailing Address - Zip Code:85622-4648
Mailing Address - Country:US
Mailing Address - Phone:520-399-9212
Mailing Address - Fax:
Practice Address - Street 1:3280 S CAMINO DEL SOL STE 124
Practice Address - Street 2:
Practice Address - City:GREEN VALLEY
Practice Address - State:AZ
Practice Address - Zip Code:85622-4648
Practice Address - Country:US
Practice Address - Phone:520-399-9212
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2007-07-12
Last Update Date:2020-07-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AZ005382207Q00000X, 207Q00000X
MO2015020161208M00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
No208M00000XAllopathic & Osteopathic PhysiciansHospitalist
Provider Identifiers
StateIdentifier IDID TypeIssuer
MOMA2082Medicare PIN