Provider Demographics
NPI:1134159023
Name:MAHAN, BRYAN M (DO)
Entity type:Individual
Prefix:
First Name:BRYAN
Middle Name:M
Last Name:MAHAN
Suffix:
Gender:M
Credentials:DO
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:5450 WESTERN AVE STE B
Mailing Address - Street 2:
Mailing Address - City:BOULDER
Mailing Address - State:CO
Mailing Address - Zip Code:80301-2709
Mailing Address - Country:US
Mailing Address - Phone:303-442-2395
Mailing Address - Fax:303-442-1073
Practice Address - Street 1:4743 ARAPAHOE AVE STE 201
Practice Address - Street 2:
Practice Address - City:BOULDER
Practice Address - State:CO
Practice Address - Zip Code:80303-1128
Practice Address - Country:US
Practice Address - Phone:303-442-2395
Practice Address - Fax:303-442-1073
Is Sole Proprietor?:No
Enumeration Date:2006-07-04
Last Update Date:2018-10-24
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CO37687208G00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208G00000XAllopathic & Osteopathic PhysiciansThoracic Surgery (Cardiothoracic Vascular Surgery)
Provider Identifiers
StateIdentifier IDID TypeIssuer
COCOA109732Medicare PIN
COC808086Medicare PIN
COE37514Medicare UPIN
COE37514Medicare UPIN
COCOA109732Medicare PIN