Provider Demographics
NPI:1245640291
Name:CROSS, BRYAN (DO)
Entity type:Individual
Prefix:DR
First Name:BRYAN
Middle Name:
Last Name:CROSS
Suffix:
Gender:M
Credentials:DO
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
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Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2495 SHREVEPORT HWY (VA MEDICAL CENTER)
Mailing Address - Street 2:MAIL CODE 112
Mailing Address - City:PINEVILLE
Mailing Address - State:LA
Mailing Address - Zip Code:71360
Mailing Address - Country:US
Mailing Address - Phone:318-466-4034
Mailing Address - Fax:575-397-1012
Practice Address - Street 1:2495 SHREVEPORT HWY (VA MEDICAL CENTER)
Practice Address - Street 2:MAIL CODE 112
Practice Address - City:PINEVILLE
Practice Address - State:LA
Practice Address - Zip Code:71360
Practice Address - Country:US
Practice Address - Phone:318-466-4034
Practice Address - Fax:575-397-1012
Is Sole Proprietor?:Yes
Enumeration Date:2014-04-29
Last Update Date:2020-06-24
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NMA-2048-17208C00000X
390200000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208C00000XAllopathic & Osteopathic PhysiciansColon & Rectal Surgery
No390200000XStudent, Health CareStudent in an Organized Health Care Education/Training Program
Provider Identifiers
StateIdentifier IDID TypeIssuer
NM000B4739Medicaid