Basic Information
| Provider Information | |||||||||
| NPI: | 1114107828 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | MEJIA | ||||||||
| FirstName: | BRYAN | ||||||||
| MiddleName: | ARMANDO | ||||||||
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| Credential: | MD | ||||||||
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| Mailing Information | |||||||||
| Address1: | 3555 KNICKERBOCKER RD | ||||||||
| Address2: | |||||||||
| City: | SAN ANGELO | ||||||||
| State: | TX | ||||||||
| PostalCode: | 769047610 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 3259499555 | ||||||||
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| Practice Location | |||||||||
| Address1: | 220 E. HARRIS | ||||||||
| Address2: | |||||||||
| City: | SAN ANGELO | ||||||||
| State: | TX | ||||||||
| PostalCode: | 76903 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 3254812285 | ||||||||
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| Other Information | |||||||||
| ProviderEnumerationDate: | 11/09/2007 | ||||||||
| LastUpdateDate: | 03/11/2021 | ||||||||
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| ProviderGenderCode: | M | ||||||||
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| IsSoleProprietor: | N | ||||||||
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| NPICertificationDate: | 03/11/2021 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 207R00000X | P9224 | TX | Y | Allopathic & Osteopathic Physicians | Internal Medicine |
ID Information
| ID | Type | State | Issuer | Description | 335797YKRY | 01 | TX | MEDICARE PTAN | OTHER | 333978002 | 05 | TX | MEDICAID |