Healthcare Provider Details

I. General information

NPI: 1285695528
Provider Name (Legal Business Name): THOMAS JOHN BRYAN OD
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 03/28/2006
Last Update Date: 06/30/2026
Certification Date: 06/30/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

424 W STATE HIGHWAY 5
WACONIA MN
55387-1795
US

IV. Provider business mailing address

424 W STATE HIGHWAY 5
WACONIA MN
55387-1795
US

V. Phone/Fax

Practice location:
  • Phone: 952-442-4461
  • Fax: 952-442-1547
Mailing address:
  • Phone: 952-442-4461
  • Fax: 952-442-1547

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code152W00000X
TaxonomyOptometrist
License Number3012
License Number StateMN

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: