=====================================================
General NPI Number Information
=====================================================
NPI Number | 1912241175
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | EDWARD G BRYANT IV OD PLLC
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 11/12/2012
-----------------------------------------------------
Last Update Date | 04/16/2019
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 1284 DRYDEN ROAD
-----------------------------------------------------
City | ITHACA
-----------------------------------------------------
State | NY
-----------------------------------------------------
Zip | 14850-8795
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 607-257-1066
-----------------------------------------------------
Fax | 607-257-1378
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 1284 DRYDEN ROAD
-----------------------------------------------------
City | ITHACA
-----------------------------------------------------
State | NY
-----------------------------------------------------
Zip | 14850-8795
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 607-257-1066
-----------------------------------------------------
Fax | 607-257-1378
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | OWNER
-----------------------------------------------------
Name | DR. EDWARD G BRYANT IV IV
-----------------------------------------------------
Credential | OD
-----------------------------------------------------
Telephone | 607-257-1066
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 152W00000X
-----------------------------------------------------
Taxonomy Name | Optometrist
-----------------------------------------------------
License Number | TUV006637
-----------------------------------------------------
License Number State | NY
-----------------------------------------------------