1932169539 NPI number — KIMBERLEY BROOKE BRYANT DO

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1932169539 NPI number — KIMBERLEY BROOKE BRYANT DO

Employer Identification Number (EIN):

Provider Organization Name:

Provider Last Name:

BRYANT

Provider First Name:

KIMBERLEY

Provider Middle Name:

BROOKE

Provider Name Prefix Text:

Provider Name Suffix Text:

Provider Credential Text:

DO

Provider Gender Code:

F

Provider Other Organization Name:

Provider Other Organization Name Type Code:

Provider Other Last Name:

CRAIG

Provider Other First Name:

KIMBERLEY

Provider Other Middle Name:

BROOKE

Provider Other Name Prefix Text:

Provider Other Name Suffix Text:

Provider Other Credential Text:

DO

Provider Other Last Name Type Code:

1

NPI Number:

1932169539

Entity Type Code:

Individual

Replacement NPI:

Last Update Date:

10/31/2015

NPI Deactivation Reason Code:

NPI Deactivation Date:

NPI Reactivation Date:

Provider First Line Business Mailing Address:

PO BOX 846098

Provider Second Line Business Mailing Address:

Provider Business Mailing Address City Name:

DALLAS

Provider Business Mailing Address State Name:

TX

Provider Business Mailing Address Postal Code:

75284-6098

Provider Business Mailing Address Country Code:

US

Provider Business Mailing Address Telephone Number:

903-324-6450

Provider Business Mailing Address Fax Number:

Provider First Line Business Practice Location Address:

520 E. DOUGLAS BLVD

Provider Second Line Business Practice Location Address:

Provider Business Practice Location Address City Name:

TYLER

Provider Business Practice Location Address State Name:

TX

Provider Business Practice Location Address Postal Code:

75702-8307

Provider Business Practice Location Address Country Code:

US

Provider Business Practice Location Address Telephone Number:

903-593-1721

Provider Business Practice Location Address Fax Number:

903-510-1108

Provider Enumeration Date:

03/27/2006

Authorized Official Last Name:

Authorized Official First Name:

Authorized Official Middle Name:

Authorized Official Title or Position:

Authorized Official Telephone Number:

• Taxonomy code: 207R00000X , with the licence number:  0116015548 , registered in the state of VA ; information, associated with the NPI states the following Primary Taxonomy Switch: "N" .
• Taxonomy code: 207R00000X , with the licence number: M6547 , registered in the state of TX ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

• Identifier: 188546904 , issued by the state of ( TX ) . This identifiers is of the category "MEDICAID".
• Identifier: 752616977118 . This is a "TRICARE" identifier , issued by the state of ( TX ) . This identifiers is of the category "OTHER".
• Identifier: 188546903 , issued by the state of ( TX ) . This identifiers is of the category "MEDICAID".
• Identifier: 75-2616977-042 . This is a "TRICARE" identifier , issued by the state of ( TX ) . This identifiers is of the category "OTHER".
• Identifier: 752616977007 . This is a "TRICARE" identifier , issued by the state of ( TX ) . This identifiers is of the category "OTHER".
• Identifier: 8FD278 . This is a "BCBS" identifier , issued by the state of ( TX ) . This identifiers is of the category "OTHER".
• Identifier: 188546902 , issued by the state of ( TX ) . This identifiers is of the category "MEDICAID".
• Identifier: P00862545 . This is a "MEDICARE RAILROAD" identifier , issued by the state of ( TX ) . This identifiers is of the category "OTHER".
• Identifier: 45-2578435-002 . This is a "TRICARE" identifier , issued by the state of ( TX ) . This identifiers is of the category "OTHER".
• Identifier: 8V3856 . This is a "BCBS" identifier , issued by the state of ( TX ) . This identifiers is of the category "OTHER".
• Identifier: P01502424 . This is a "RAIL ROAD" identifier , issued by the state of ( TX ) . This identifiers is of the category "OTHER".