Provider Demographics
NPI:1932169539
Name:BRYANT, KIMBERLEY BROOKE (DO)
Entity Type:Individual
Prefix:
First Name:KIMBERLEY
Middle Name:BROOKE
Last Name:BRYANT
Suffix:
Gender:F
Credentials:DO
Other - Prefix:
Other - First Name:KIMBERLEY
Other - Middle Name:BROOKE
Other - Last Name:CRAIG
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:DO
Mailing Address - Street 1:PO BOX 846098
Mailing Address - Street 2:
Mailing Address - City:DALLAS
Mailing Address - State:TX
Mailing Address - Zip Code:75284-6098
Mailing Address - Country:US
Mailing Address - Phone:903-324-6450
Mailing Address - Fax:
Practice Address - Street 1:520 E. DOUGLAS BLVD
Practice Address - Street 2:
Practice Address - City:TYLER
Practice Address - State:TX
Practice Address - Zip Code:75702-8307
Practice Address - Country:US
Practice Address - Phone:903-593-1721
Practice Address - Fax:903-510-1108
Is Sole Proprietor?:No
Enumeration Date:2006-03-27
Last Update Date:2015-10-31
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
VA0116015548207R00000X
TXM6547207R00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207R00000XAllopathic & Osteopathic PhysiciansInternal Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
TX188546904Medicaid
TX752616977118OtherTRICARE
TX188546903Medicaid
TX75-2616977-042OtherTRICARE
TX752616977007OtherTRICARE
TX8FD278OtherBCBS
TX188546902Medicaid
TXP00862545OtherMEDICARE RAILROAD
TX45-2578435-002OtherTRICARE
TX8V3856OtherBCBS
TXP01502424OtherRAIL ROAD
TX45-2578435-002OtherTRICARE
TX8K0372Medicare PIN
TX752616977007OtherTRICARE
TX188546904Medicaid
TX415773YR7VMedicare PIN