Provider Demographics
NPI:1356924476
Name:WITCHER, BRYCEN (MD)
Entity type:Individual
Prefix:
First Name:BRYCEN
Middle Name:
Last Name:WITCHER
Suffix:
Gender:
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:3860 HAWTHORNE DR
Mailing Address - Street 2:
Mailing Address - City:JACKSON
Mailing Address - State:MS
Mailing Address - Zip Code:39206-5827
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:1308 PALUXY RD STE E
Practice Address - Street 2:
Practice Address - City:GRANBURY
Practice Address - State:TX
Practice Address - Zip Code:76048-5689
Practice Address - Country:US
Practice Address - Phone:817-573-2273
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2021-05-05
Last Update Date:2025-05-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MS31788207Q00000X
261QM2500X
MS261QS1000X
TXV6425208VP0014X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208VP0014XAllopathic & Osteopathic PhysiciansPain MedicineInterventional Pain Medicine
No207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
No261QM2500XAmbulatory Health Care FacilitiesClinic/CenterMedical Specialty
No261QS1000XAmbulatory Health Care FacilitiesClinic/CenterStudent Health