Basic Information
| Provider Information | |||||||||
| NPI: | 1881691764 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | KAUFMAN | ||||||||
| FirstName: | BRYAN | ||||||||
| MiddleName: | LEE | ||||||||
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| Credential: | M.D. | ||||||||
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| Mailing Information | |||||||||
| Address1: | 4136 STOWE RUN LN | ||||||||
| Address2: | STE 204 | ||||||||
| City: | JACKSONVILLE | ||||||||
| State: | FL | ||||||||
| PostalCode: | 322251622 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 2162555743 | ||||||||
| FaxNumber: | 8667353451 | ||||||||
| Practice Location | |||||||||
| Address1: | 4136 STOWE RUN LN | ||||||||
| Address2: | |||||||||
| City: | JACKSONVILLE | ||||||||
| State: | FL | ||||||||
| PostalCode: | 322251622 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8283899740 | ||||||||
| FaxNumber: | 8667353451 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 07/07/2005 | ||||||||
| LastUpdateDate: | 02/13/2017 | ||||||||
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| ProviderGenderCode: | M | ||||||||
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| IsSoleProprietor: | N | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 2085R0202X | ME74867 | FL | Y | Allopathic & Osteopathic Physicians | Radiology | Diagnostic Radiology |
ID Information
| ID | Type | State | Issuer | Description | 300110020 | 01 | RR | OTHER | 43420 | 01 | BCBS | OTHER | 259066200 | 05 | FL | MEDICAID |