Healthcare Provider Details

I. General information

NPI: 1528035888
Provider Name (Legal Business Name): GREGORY W BRYAN DPM
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 03/07/2006
Last Update Date: 07/21/2011
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

385 BERT KOUNS BLDG. 200
SHREVEPORT LA
71106-8158
US

IV. Provider business mailing address

385 BERT KOUNS BLDG. 200
SHREVEPORT LA
71106-8158
US

V. Phone/Fax

Practice location:
  • Phone: 318-687-8447
  • Fax: 318-687-9950
Mailing address:
  • Phone: 318-687-8447
  • Fax: 318-687-9950

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code213ES0131X
TaxonomyFoot Surgery Podiatrist
License NumberPD067R
License Number StateLA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: