Provider Demographics
NPI:1639442619
Name:GHANNY, BRYAN ABDUL (MD)
Entity type:Individual
Prefix:DR
First Name:BRYAN
Middle Name:ABDUL
Last Name:GHANNY
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2 CALAIS PL
Mailing Address - Street 2:
Mailing Address - City:MONTVILLE
Mailing Address - State:NJ
Mailing Address - Zip Code:07045-9551
Mailing Address - Country:US
Mailing Address - Phone:973-229-4288
Mailing Address - Fax:
Practice Address - Street 1:200 WASHINGTON ST
Practice Address - Street 2:
Practice Address - City:NEWARK
Practice Address - State:NJ
Practice Address - Zip Code:07102-2921
Practice Address - Country:US
Practice Address - Phone:973-622-3890
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2012-02-21
Last Update Date:2023-02-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
390200000X
NJ25MA09804900208000000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes208000000XAllopathic & Osteopathic PhysiciansPediatricsGroup - Single Specialty
No390200000XStudent, Health CareStudent in an Organized Health Care Education/Training Program