Provider Demographics
NPI:1952922270
Name:BRYAN, GLENN EDMUND JR
Entity Type:Individual
Prefix:DR
First Name:GLENN
Middle Name:EDMUND
Last Name:BRYAN
Suffix:JR
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:4255 N US HIGHWAY 1
Mailing Address - Street 2:
Mailing Address - City:MELBOURNE
Mailing Address - State:FL
Mailing Address - Zip Code:32935-4822
Mailing Address - Country:US
Mailing Address - Phone:321-259-6797
Mailing Address - Fax:
Practice Address - Street 1:4255 N US HIGHWAY 1
Practice Address - Street 2:
Practice Address - City:MELBOURNE
Practice Address - State:FL
Practice Address - Zip Code:32935-4822
Practice Address - Country:US
Practice Address - Phone:321-543-0379
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2020-04-27
Last Update Date:2020-04-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLME0037596208600000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208600000XAllopathic & Osteopathic PhysiciansSurgery
Provider Identifiers
StateIdentifier IDID TypeIssuer
FLME0037596OtherSTATE LICENSE