Provider Demographics
NPI:1932177557
Name:BRYAN, CYNTHIA BLACKWELL
Entity Type:Individual
Prefix:
First Name:CYNTHIA
Middle Name:BLACKWELL
Last Name:BRYAN
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1001 COLLEGE BLVD W
Mailing Address - Street 2:SUITE G
Mailing Address - City:NICEVILLE
Mailing Address - State:FL
Mailing Address - Zip Code:32578-1099
Mailing Address - Country:US
Mailing Address - Phone:850-897-1700
Mailing Address - Fax:850-897-1792
Practice Address - Street 1:1001 WEST COLLEGE BOULEVARD
Practice Address - Street 2:SUITE G
Practice Address - City:NICEVILLE
Practice Address - State:FL
Practice Address - Zip Code:32578-1049
Practice Address - Country:US
Practice Address - Phone:850-897-1700
Practice Address - Fax:850-897-1792
Is Sole Proprietor?:Yes
Enumeration Date:2006-03-09
Last Update Date:2015-05-30
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLME80397207R00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207R00000XAllopathic & Osteopathic PhysiciansInternal Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
FL259143000Medicaid
FL110233921OtherRAILROAD MEDICARE
FL35711OtherBLUE CROSS/BLUE SHIELD FL
FL110233921OtherRAILROAD MEDICARE
FL35711OtherBLUE CROSS/BLUE SHIELD FL
00035711Medicare PIN