Provider Demographics
NPI:1750876991
Name:BOURDEAU, BRYAN THOMAS (MD)
Entity type:Individual
Prefix:DR
First Name:BRYAN
Middle Name:THOMAS
Last Name:BOURDEAU
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 1:330 BROOKLINE AVE
Mailing Address - Street 2:
Mailing Address - City:BOSTON
Mailing Address - State:MA
Mailing Address - Zip Code:02215-5491
Mailing Address - Country:US
Mailing Address - Phone:617-667-7000
Mailing Address - Fax:
Practice Address - Street 1:521 PARNASSUS AVE
Practice Address - Street 2:
Practice Address - City:SAN FRANCISCO
Practice Address - State:CA
Practice Address - Zip Code:94143-2206
Practice Address - Country:US
Practice Address - Phone:415-476-1000
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2018-06-29
Last Update Date:2025-05-04
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MA276390390200000X
CAA202521207R00000X
MA286471207R00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207R00000XAllopathic & Osteopathic PhysiciansInternal Medicine
No390200000XStudent, Health CareStudent in an Organized Health Care Education/Training Program