Provider Demographics
NPI:1356339360
Name:TREACY, BRYAN (MD)
Entity type:Individual
Prefix:DR
First Name:BRYAN
Middle Name:
Last Name:TREACY
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 6847
Mailing Address - Street 2:
Mailing Address - City:MOORE
Mailing Address - State:OK
Mailing Address - Zip Code:73153-0847
Mailing Address - Country:US
Mailing Address - Phone:405-793-9171
Mailing Address - Fax:405-793-0815
Practice Address - Street 1:1035 SW 19TH ST
Practice Address - Street 2:SUITE B
Practice Address - City:MOORE
Practice Address - State:OK
Practice Address - Zip Code:73160-2883
Practice Address - Country:US
Practice Address - Phone:405-793-9171
Practice Address - Fax:405-793-0815
Is Sole Proprietor?:Yes
Enumeration Date:2005-10-12
Last Update Date:2010-03-30
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OK23781207VX0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207VX0000XAllopathic & Osteopathic PhysiciansObstetrics & GynecologyObstetrics
Provider Identifiers
StateIdentifier IDID TypeIssuer
OK200036180AMedicaid
OK200036180AMedicaid
OKOK700723Medicare PIN