Provider Demographics
NPI:1831104991
Name:IRVIN, BRYAN T (MD)
Entity Type:Individual
Prefix:
First Name:BRYAN
Middle Name:T
Last Name:IRVIN
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:PO BOX 26726
Mailing Address - Street 2:
Mailing Address - City:AUSTIN
Mailing Address - State:TX
Mailing Address - Zip Code:78755-0726
Mailing Address - Country:US
Mailing Address - Phone:512-407-8686
Mailing Address - Fax:512-421-4489
Practice Address - Street 1:940 HESTERS CROSSING
Practice Address - Street 2:
Practice Address - City:ROUND ROCK
Practice Address - State:TX
Practice Address - Zip Code:78681-8018
Practice Address - Country:US
Practice Address - Phone:512-244-9024
Practice Address - Fax:512-218-3704
Is Sole Proprietor?:No
Enumeration Date:2006-07-29
Last Update Date:2011-01-04
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TXH2485207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
TX101984602Medicaid
TX101984603Medicaid
TX8653J5Medicare PIN
TX101984602Medicaid
TX81720KMedicare PIN
TX101984603Medicaid
TX080181864Medicare PIN