Basic Information
| Provider Information | |||||||||
| NPI: | 1104023308 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | RIGGEAL | ||||||||
| FirstName: | BRYAN | ||||||||
| MiddleName: | DOUGLAS | ||||||||
| NamePrefix: | DR. | ||||||||
| NameSuffix: | |||||||||
| Credential: | M.D. | ||||||||
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| Mailing Information | |||||||||
| Address1: | PO BOX 746649 | ||||||||
| Address2: | |||||||||
| City: | ATLANTA | ||||||||
| State: | GA | ||||||||
| PostalCode: | 303746649 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 9043764400 | ||||||||
| FaxNumber: | 9043915595 | ||||||||
| Practice Location | |||||||||
| Address1: | 841 PRUDENTIAL DR FL 10 | ||||||||
| Address2: | |||||||||
| City: | JACKSONVILLE | ||||||||
| State: | FL | ||||||||
| PostalCode: | 322078329 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 9043985404 | ||||||||
| FaxNumber: | 9043915545 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 06/29/2007 | ||||||||
| LastUpdateDate: | 10/25/2022 | ||||||||
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| ProviderGenderCode: | M | ||||||||
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| IsSoleProprietor: | N | ||||||||
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| NPICertificationDate: | 10/25/2022 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 207W00000X | ME128272 | FL | N | Allopathic & Osteopathic Physicians | Ophthalmology | 207W00000X | 66311 | GA | N | Allopathic & Osteopathic Physicians | Ophthalmology | 2084N0400X | 66311 | GA | N | Allopathic & Osteopathic Physicians | Psychiatry & Neurology | Neurology | 2084N0400X | ME128272 | FL | N | Allopathic & Osteopathic Physicians | Psychiatry & Neurology | Neurology | 207WX0109X | ME128272 | FL | Y |
ID Information
| ID | Type | State | Issuer | Description | 018248700 | 05 | FL | MEDICAID |