Provider Demographics
NPI:1750417879
Name:BRYANT, KEVIN R
Entity type:Individual
Prefix:
First Name:KEVIN
Middle Name:R
Last Name:BRYANT
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 1:2138 W GENESEE ST
Mailing Address - Street 2:
Mailing Address - City:SYRACUSE
Mailing Address - State:NY
Mailing Address - Zip Code:13219-1616
Mailing Address - Country:US
Mailing Address - Phone:315-488-2814
Mailing Address - Fax:
Practice Address - Street 1:2138 W GENESEE ST
Practice Address - Street 2:
Practice Address - City:SYRACUSE
Practice Address - State:NY
Practice Address - Zip Code:13219-1616
Practice Address - Country:US
Practice Address - Phone:315-488-2814
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2007-02-25
Last Update Date:2008-06-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NYC003141-1156FX1800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes156FX1800XEye and Vision Services ProvidersTechnician/TechnologistOptician
Provider Identifiers
StateIdentifier IDID TypeIssuer
NY16-6173145OtherEMPLOYER ID NUMBER
NY0576840001Medicare NSC