Provider Demographics
NPI:1780115618
Name:SOUDER, BRIANNA (DO)
Entity type:Individual
Prefix:
First Name:BRIANNA
Middle Name:
Last Name:SOUDER
Suffix:
Gender:F
Credentials:DO
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:909 E SE LOOP 323 STE 360
Mailing Address - Street 2:
Mailing Address - City:TYLER
Mailing Address - State:TX
Mailing Address - Zip Code:75701-9101
Mailing Address - Country:US
Mailing Address - Phone:903-393-3169
Mailing Address - Fax:903-508-6154
Practice Address - Street 1:909 E SE LOOP 323 STE 360
Practice Address - Street 2:
Practice Address - City:TYLER
Practice Address - State:TX
Practice Address - Zip Code:75701-9101
Practice Address - Country:US
Practice Address - Phone:903-393-3169
Practice Address - Fax:903-508-6154
Is Sole Proprietor?:No
Enumeration Date:2017-03-22
Last Update Date:2024-06-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NC2020-00828208000000X
390200000X
TXV22792080P0202X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2080P0202XAllopathic & Osteopathic PhysiciansPediatricsPediatric Cardiology
No208000000XAllopathic & Osteopathic PhysiciansPediatrics
No390200000XStudent, Health CareStudent in an Organized Health Care Education/Training Program
Provider Identifiers
StateIdentifier IDID TypeIssuer
NC2020-00828OtherNORTH CAROLINA MEDICAL BOARD
TXV2279OtherTEXAS MEDICAL BOARD