Provider Demographics
NPI:1912935305
Name:SMITH, BRYAN C (MD)
Entity type:Individual
Prefix:
First Name:BRYAN
Middle Name:C
Last Name:SMITH
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1360 S BERETANIA ST
Mailing Address - Street 2:STE. 215
Mailing Address - City:HONOLULU
Mailing Address - State:HI
Mailing Address - Zip Code:96814-1520
Mailing Address - Country:US
Mailing Address - Phone:808-532-3600
Mailing Address - Fax:808-538-3220
Practice Address - Street 1:1360 S BERETANIA ST
Practice Address - Street 2:STE. 215
Practice Address - City:HONOLULU
Practice Address - State:HI
Practice Address - Zip Code:96814-1520
Practice Address - Country:US
Practice Address - Phone:808-532-3600
Practice Address - Fax:808-538-3220
Is Sole Proprietor?:No
Enumeration Date:2006-06-28
Last Update Date:2008-10-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAG79262207L00000X
HI13687207L00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207L00000XAllopathic & Osteopathic PhysiciansAnesthesiology
Provider Identifiers
StateIdentifier IDID TypeIssuer
CA00G792620OtherBLUE SHIELD OF CA
CA00G792620Medicaid
CA00G792620OtherBLUE SHIELD OF CA
CAG47376Medicare UPIN