Provider Demographics
NPI:1669150264
Name:PETERS, BRYAN THOMAS
Entity type:Individual
Prefix:MR
First Name:BRYAN
Middle Name:THOMAS
Last Name:PETERS
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:3503 TIFTON LN
Mailing Address - Street 2:
Mailing Address - City:OPELIKA
Mailing Address - State:AL
Mailing Address - Zip Code:36804-7651
Mailing Address - Country:US
Mailing Address - Phone:334-559-4673
Mailing Address - Fax:
Practice Address - Street 1:3503 TIFTON LN
Practice Address - Street 2:
Practice Address - City:OPELIKA
Practice Address - State:AL
Practice Address - Zip Code:36804-7651
Practice Address - Country:US
Practice Address - Phone:334-559-4673
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2023-07-05
Last Update Date:2023-07-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AL1676171W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes171W00000XOther Service ProvidersContractor