MEDICARE: MARA NICOLE BRYAN MD

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	207Q00000X	Family Medicine Physician	35.151847	OH
2	390200000X	Student in an Organized Health Care Education/Training Program

General Provider Information

NPI Number	:	1013667823
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	MARA NICOLE BRYAN MD

Provider Business Mailing Address
First Line	:	1 PRESTIGE PL STE 550
Second Line	:
City	:	MIAMISBURG
State	:	OH
Zip	:	45342-6115
Country	:	US
Telephone Number	:	937-762-1310
Fax Number	:

Provider Business Practice Location Address
First Line	:	6438 WILMINGTON PIKE STE 100
Second Line	:
City	:	DAYTON
State	:	OH
Zip	:	45459-7021
Country	:	US
Telephone Number	:	937-558-3840
Fax Number	:	937-558-3844

Authorized Official
Title or Position	:
Name	:
Credential	:
Telephone Number	:

Provider Enumeration Date	:	03/25/2022
Last Update Date	:	10/02/2025

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