Provider Demographics
NPI:1942371273
Name:OWEN, BRYAN JOE (PT)
Entity Type:Individual
Prefix:MR
First Name:BRYAN
Middle Name:JOE
Last Name:OWEN
Suffix:
Gender:M
Credentials:PT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:21 MOUNTAINVIEW CT
Mailing Address - Street 2:
Mailing Address - City:CEDARTOWN
Mailing Address - State:GA
Mailing Address - Zip Code:30125-4688
Mailing Address - Country:US
Mailing Address - Phone:770-855-0977
Mailing Address - Fax:404-795-0690
Practice Address - Street 1:119 E GIRARD AVE
Practice Address - Street 2:
Practice Address - City:CEDARTOWN
Practice Address - State:GA
Practice Address - Zip Code:30125-2711
Practice Address - Country:US
Practice Address - Phone:770-855-0977
Practice Address - Fax:404-795-0690
Is Sole Proprietor?:Yes
Enumeration Date:2006-11-10
Last Update Date:2007-07-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GAGA 0048902251P0200X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2251P0200XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical TherapistPediatrics
Provider Identifiers
StateIdentifier IDID TypeIssuer
GA10036138OtherAMERIGROUP
GA330841OtherWELL CARE