Provider Demographics
NPI:1821007949
Name:BRYANT, KENNETH LANCE (DO)
Entity Type:Individual
Prefix:
First Name:KENNETH
Middle Name:LANCE
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 1:200 SAINT CLAIR AVE
Mailing Address - Street 2:
Mailing Address - City:SAINT MARYS
Mailing Address - State:OH
Mailing Address - Zip Code:45885-2400
Mailing Address - Country:US
Mailing Address - Phone:419-300-1129
Mailing Address - Fax:419-394-9575
Practice Address - Street 1:1140 S KNOXVILLE AVE STE C
Practice Address - Street 2:
Practice Address - City:SAINT MARYS
Practice Address - State:OH
Practice Address - Zip Code:45885-2609
Practice Address - Country:US
Practice Address - Phone:419-394-9595
Practice Address - Fax:419-394-9532
Is Sole Proprietor?:No
Enumeration Date:2006-08-07
Last Update Date:2021-04-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OH34-005959208600000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208600000XAllopathic & Osteopathic PhysiciansSurgery
Provider Identifiers
StateIdentifier IDID TypeIssuer
OH1184652539OtherGROUP NPI - JTDM FAMILY PRACTICE, LLC
OH0989097Medicaid
OH34-1689161OtherTAX ID
OHH039441OtherMEDICARE