Basic Information
| Provider Information | |||||||||
| NPI: | 1982925913 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | BRYAN | ||||||||
| FirstName: | BRIDGET | ||||||||
| MiddleName: | DIANE | ||||||||
| NamePrefix: | DR. | ||||||||
| NameSuffix: | |||||||||
| Credential: | D.O. | ||||||||
| OtherOrganizationName: | |||||||||
| OtherOrganizationType: | |||||||||
| OtherLastName: | FLAUDING | ||||||||
| OtherFirstName: | BRIDGET | ||||||||
| OtherMiddleName: | DIANE | ||||||||
| OtherNamePrefix: | DR. | ||||||||
| OtherNameSuffix: | |||||||||
| OtherCredential: | D.O. | ||||||||
| OtherLastNameType: | 1 | ||||||||
| Mailing Information | |||||||||
| Address1: | 2100 W IOWA AVE | ||||||||
| Address2: | SUITE A | ||||||||
| City: | CHICKASHA | ||||||||
| State: | OK | ||||||||
| PostalCode: | 730182736 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 4052242100 | ||||||||
| FaxNumber: | 4057792365 | ||||||||
| Practice Location | |||||||||
| Address1: | 2100 W IOWA AVE | ||||||||
| Address2: | SUITE A | ||||||||
| City: | CHICKASHA | ||||||||
| State: | OK | ||||||||
| PostalCode: | 730182736 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 4052242100 | ||||||||
| FaxNumber: | 4057792365 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 06/14/2010 | ||||||||
| LastUpdateDate: | 08/16/2016 | ||||||||
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| ProviderGenderCode: | F | ||||||||
| AuthorizedOfficialLastName: | |||||||||
| AuthorizedOfficialFirstName: | |||||||||
| AuthorizedOfficialMiddleName: | |||||||||
| AuthorizedOfficialTitleorPosition: | |||||||||
| AuthorizedOfficialTelephone: | |||||||||
| IsSoleProprietor: | N | ||||||||
| IsOrganizationSubpart: | |||||||||
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| AuthorizedOfficialNamePrefix: | |||||||||
| AuthorizedOfficialNameSuffix: | |||||||||
| AuthorizedOfficialCredential: | |||||||||
| NPICertificationDate: | |||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 208000000X | 5036 | OK | Y | Allopathic & Osteopathic Physicians | Pediatrics |
ID Information
| ID | Type | State | Issuer | Description | 200397150A | 05 | OK | MEDICAID |