Provider Demographics
NPI:1023053972
Name:MUTCHLER, BRYANT A (DO)
Entity type:Individual
Prefix:DR
First Name:BRYANT
Middle Name:A
Last Name:MUTCHLER
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 1:3200 W KIMBERLY RD STE 200
Mailing Address - Street 2:
Mailing Address - City:DAVENPORT
Mailing Address - State:IA
Mailing Address - Zip Code:52806-3059
Mailing Address - Country:US
Mailing Address - Phone:563-421-0268
Mailing Address - Fax:563-421-0269
Practice Address - Street 1:3200 W KIMBERLY RD STE 200
Practice Address - Street 2:
Practice Address - City:DAVENPORT
Practice Address - State:IA
Practice Address - Zip Code:52806-3059
Practice Address - Country:US
Practice Address - Phone:563-421-0268
Practice Address - Fax:563-421-0269
Is Sole Proprietor?:No
Enumeration Date:2006-06-17
Last Update Date:2021-07-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IA02822207Q00000X
IA2822207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
IA1235713Medicaid
IA31942OtherBLUE CROSS WELLMARK
IAIA0150OtherUHC OF RIVER VALLEY (JDH)
IAP00383256OtherRAILROAD MEDICARE
IA1235713Medicaid
IAF77920Medicare UPIN