Healthcare Provider Details

I. General information

NPI: 1013667823
Provider Name (Legal Business Name): MARA NICOLE BRYAN MD
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 03/25/2022
Last Update Date: 10/02/2025
Certification Date: 10/02/2025
Deactivation Date:
Reactivation Date:

III. Provider practice location address

6438 WILMINGTON PIKE STE 100
DAYTON OH
45459-7021
US

IV. Provider business mailing address

1 PRESTIGE PL STE 550
MIAMISBURG OH
45342-6115
US

V. Phone/Fax

Practice location:
  • Phone: 937-558-3840
  • Fax: 937-558-3844
Mailing address:
  • Phone: 937-762-1310
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code390200000X
TaxonomyStudent in an Organized Health Care Education/Training Program
License Number
License Number StateNULL
# 2
Primary TaxonomyY
Taxonomy Code207Q00000X
TaxonomyFamily Medicine Physician
License Number35.151847
License Number StateOH

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: