Basic Information
| Provider Information | |||||||||
| NPI: | 1932169539 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | BRYANT | ||||||||
| FirstName: | KIMBERLEY | ||||||||
| MiddleName: | BROOKE | ||||||||
| NamePrefix: | |||||||||
| NameSuffix: | |||||||||
| Credential: | DO | ||||||||
| OtherOrganizationName: | |||||||||
| OtherOrganizationType: | |||||||||
| OtherLastName: | CRAIG | ||||||||
| OtherFirstName: | KIMBERLEY | ||||||||
| OtherMiddleName: | BROOKE | ||||||||
| OtherNamePrefix: | |||||||||
| OtherNameSuffix: | |||||||||
| OtherCredential: | DO | ||||||||
| OtherLastNameType: | 1 | ||||||||
| Mailing Information | |||||||||
| Address1: | PO BOX 846098 | ||||||||
| Address2: | |||||||||
| City: | DALLAS | ||||||||
| State: | TX | ||||||||
| PostalCode: | 752846098 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 9033246450 | ||||||||
| FaxNumber: | |||||||||
| Practice Location | |||||||||
| Address1: | 520 E. DOUGLAS BLVD | ||||||||
| Address2: | |||||||||
| City: | TYLER | ||||||||
| State: | TX | ||||||||
| PostalCode: | 757028307 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 9035931721 | ||||||||
| FaxNumber: | 9035101108 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 03/27/2006 | ||||||||
| LastUpdateDate: | 10/31/2015 | ||||||||
| NPIDeactivationReasonCode: | |||||||||
| NPIDeactivationDate: | |||||||||
| NPIReactivationDate: | |||||||||
| ProviderGenderCode: | F | ||||||||
| AuthorizedOfficialLastName: | |||||||||
| AuthorizedOfficialFirstName: | |||||||||
| AuthorizedOfficialMiddleName: | |||||||||
| AuthorizedOfficialTitleorPosition: | |||||||||
| AuthorizedOfficialTelephone: | |||||||||
| IsSoleProprietor: | N | ||||||||
| IsOrganizationSubpart: | |||||||||
| ParentOrganizationLBN: | |||||||||
| AuthorizedOfficialNamePrefix: | |||||||||
| AuthorizedOfficialNameSuffix: | |||||||||
| AuthorizedOfficialCredential: | |||||||||
| NPICertificationDate: | |||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 207R00000X | 0116015548 | VA | N | Allopathic & Osteopathic Physicians | Internal Medicine | 207R00000X | M6547 | TX | Y | Allopathic & Osteopathic Physicians | Internal Medicine |
ID Information
| ID | Type | State | Issuer | Description | 188546904 | 05 | TX | MEDICAID | 752616977118 | 01 | TX | TRICARE | OTHER | 188546903 | 05 | TX | MEDICAID | 75-2616977-042 | 01 | TX | TRICARE | OTHER | 752616977007 | 01 | TX | TRICARE | OTHER | 8FD278 | 01 | TX | BCBS | OTHER | 188546902 | 05 | TX | MEDICAID | P00862545 | 01 | TX | MEDICARE RAILROAD | OTHER | 45-2578435-002 | 01 | TX | TRICARE | OTHER | 8V3856 | 01 | TX | BCBS | OTHER | P01502424 | 01 | TX | RAIL ROAD | OTHER |