Provider Demographics
NPI:1982624136
Name:UPHAM, BRYAN D (MD)
Entity Type:Individual
Prefix:
First Name:BRYAN
Middle Name:D
Last Name:UPHAM
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:
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Other - Last Name:
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Other - Credentials:
Mailing Address - Street 1:933 BRADBURY DR SE STE 2222
Mailing Address - Street 2:
Mailing Address - City:ALBUQUERQUE
Mailing Address - State:NM
Mailing Address - Zip Code:87106-4375
Mailing Address - Country:US
Mailing Address - Phone:505-272-3120
Mailing Address - Fax:505-272-8060
Practice Address - Street 1:1 UNIVERSITY OF NEW MEXICO
Practice Address - Street 2:UNM DEPARTMENT OF EMERGENCY MEDICINE, MSC10 5560
Practice Address - City:ALBUQUERQUE
Practice Address - State:NM
Practice Address - Zip Code:87131-0001
Practice Address - Country:US
Practice Address - Phone:505-272-5062
Practice Address - Fax:505-272-6503
Is Sole Proprietor?:No
Enumeration Date:2006-07-20
Last Update Date:2011-09-14
Deactivation Date:
Deactivation Code:
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Provider Licenses
StateLicense IDTaxonomies
PAMD424533208000000X, 2080P0204X
NMMD2007-05772080P0204X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2080P0204XAllopathic & Osteopathic PhysiciansPediatricsPediatric Emergency Medicine
No208000000XAllopathic & Osteopathic PhysiciansPediatrics
Provider Identifiers
StateIdentifier IDID TypeIssuer
NJ0089869Medicaid
PA101460563Medicaid
PA101460563Medicaid