Provider Demographics
NPI:1205059128
Name:O'BRYAN, THOMAS D (DC, CCN)
Entity type:Individual
Prefix:DR
First Name:THOMAS
Middle Name:D
Last Name:O'BRYAN
Suffix:
Gender:M
Credentials:DC, CCN
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:624 SHERIDAN SQ APT 3
Mailing Address - Street 2:
Mailing Address - City:EVANSTON
Mailing Address - State:IL
Mailing Address - Zip Code:60202-4750
Mailing Address - Country:US
Mailing Address - Phone:847-733-1710
Mailing Address - Fax:847-733-1711
Practice Address - Street 1:28379 DAVIS PKWY
Practice Address - Street 2:SUITE 801
Practice Address - City:WARRENVILLE
Practice Address - State:IL
Practice Address - Zip Code:60555-3032
Practice Address - Country:US
Practice Address - Phone:630-393-9800
Practice Address - Fax:630-393-0499
Is Sole Proprietor?:Yes
Enumeration Date:2007-04-10
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL0038-4472133NN1002X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes133NN1002XDietary & Nutritional Service ProvidersNutritionistNutrition, Education