Healthcare Provider Details

I. General information

NPI: 1558326454
Provider Name (Legal Business Name): JAMES WITT BRYAN IV MD
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 04/20/2006
Last Update Date: 03/11/2024
Certification Date: 03/07/2024
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1090 ARNOLD DR 19 AMDS/SGPF
LITTLE ROCK AIR FORCE BASE AR
72099-4933
US

IV. Provider business mailing address

1090 ARNOLD DR
LITTLE ROCK AIR FORCE BASE AR
72099-4933
US

V. Phone/Fax

Practice location:
  • Phone: 501-987-7319
  • Fax: 501-987-1464
Mailing address:
  • Phone: 501-987-7319
  • Fax: 501-987-1464

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207QS0010X
TaxonomySports Medicine (Family Medicine) Physician
License NumberC-7904
License Number StateAR
# 2
Primary TaxonomyN
Taxonomy Code207Q00000X
TaxonomyFamily Medicine Physician
License NumberC-7904
License Number StateAR
# 3
Primary TaxonomyN
Taxonomy Code207Q00000X
TaxonomyFamily Medicine Physician
License NumberC7904
License Number StateAR
# 4
Primary TaxonomyN
Taxonomy Code207QS0010X
TaxonomySports Medicine (Family Medicine) Physician
License NumberC7904
License Number StateAR

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: