Provider Demographics
NPI:1538155213
Name:BRYAN, DWIGHT E (DO)
Entity type:Individual
Prefix:
First Name:DWIGHT
Middle Name:E
Last Name:BRYAN
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 1:5757 MONCLOVA RD
Mailing Address - Street 2:STE 1
Mailing Address - City:MAUMEE
Mailing Address - State:OH
Mailing Address - Zip Code:43537-1863
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:5757 MONCLOVA RD
Practice Address - Street 2:STE 1
Practice Address - City:MAUMEE
Practice Address - State:OH
Practice Address - Zip Code:43537-1863
Practice Address - Country:US
Practice Address - Phone:419-897-8417
Practice Address - Fax:419-897-8418
Is Sole Proprietor?:Yes
Enumeration Date:2005-09-27
Last Update Date:2017-05-18
Deactivation Date:2006-03-24
Deactivation Code:
Reactivation Date:2006-03-31
Provider Licenses
StateLicense IDTaxonomies
OH340037326207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
OH080188792OtherRAILROAD MEDICARE
470855160OtherFED TAX
OH0704054Medicaid
OH080188792OtherRAILROAD MEDICARE
A82982Medicare UPIN