MEDICARE: DR. CASSANDRA M BRYANT 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	208000000X	Pediatrics Physician	K6753	TX

Other Identifiers

#	Provider Identifier	Provider Identifier Type	Provider Identifier State	Provider Identifier Issuer
1	10030167	OTHER	TX	AMERIGROUP
2	MEDICAID ID Found: Get Medicaid Details using Online Medicaid Verification Program
3	101819	OTHER	TX	SUPERIOR CHIPS

General Provider Information

NPI Number	:	1174526263
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	DR. CASSANDRA M BRYANT MD

Provider Business Mailing Address
First Line	:	PO BOX 844658
Second Line	:
City	:	DALLAS
State	:	TX
Zip	:	75284-4658
Country	:	US
Telephone Number	:	800-994-0371
Fax Number	:

Provider Business Practice Location Address
First Line	:	600 N PARK ST
Second Line	:
City	:	BRENHAM
State	:	TX
Zip	:	77833
Country	:	US
Telephone Number	:	979-836-6153
Fax Number	:

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

Provider Enumeration Date	:	05/23/2005
Last Update Date	:	12/14/2021

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