Basic Information
| Provider Information | |||||||||
| NPI: | 1972614238 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | BRY | ||||||||
| FirstName: | JOHN | ||||||||
| MiddleName: | DAVID | ||||||||
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| Credential: | MD | ||||||||
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| Mailing Information | |||||||||
| Address1: | 2637 SHADELANDS DR | ||||||||
| Address2: | |||||||||
| City: | WALNUT CREEK | ||||||||
| State: | CA | ||||||||
| PostalCode: | 945982512 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 9259326330 | ||||||||
| FaxNumber: | 9259320139 | ||||||||
| Practice Location | |||||||||
| Address1: | 350 30TH ST STE 210 | ||||||||
| Address2: | |||||||||
| City: | OAKLAND | ||||||||
| State: | CA | ||||||||
| PostalCode: | 946093425 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 5108326131 | ||||||||
| FaxNumber: | 5108326169 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 08/31/2006 | ||||||||
| LastUpdateDate: | 02/06/2020 | ||||||||
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| ProviderGenderCode: | M | ||||||||
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| IsSoleProprietor: | N | ||||||||
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| NPICertificationDate: | 02/06/2020 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 2086S0129X | G79513 | CA | Y | Allopathic & Osteopathic Physicians | Surgery | Vascular Surgery |
ID Information
| ID | Type | State | Issuer | Description | 00G795130 | 05 | CA | MEDICAID |