Provider Demographics
NPI:1861574212
Name:FINE, BRYAN R (MD)
Entity type:Individual
Prefix:
First Name:BRYAN
Middle Name:R
Last Name:FINE
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 1:2300 18TH ST NW APT 304
Mailing Address - Street 2:
Mailing Address - City:WASHINGTON
Mailing Address - State:DC
Mailing Address - Zip Code:20009-1898
Mailing Address - Country:US
Mailing Address - Phone:202-368-6336
Mailing Address - Fax:
Practice Address - Street 1:111 MICHIGAN AVE NW
Practice Address - Street 2:
Practice Address - City:WASHINGTON
Practice Address - State:DC
Practice Address - Zip Code:20010-2978
Practice Address - Country:US
Practice Address - Phone:202-884-4177
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2006-10-19
Last Update Date:2008-10-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
DCMD331712080P0206X, 208000000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208000000XAllopathic & Osteopathic PhysiciansPediatrics
No2080P0206XAllopathic & Osteopathic PhysiciansPediatricsPediatric Gastroenterology
Provider Identifiers
StateIdentifier IDID TypeIssuer
VA5875196Medicaid
MD434050700Medicaid
DC034078600Medicaid
H66158Medicare UPIN
009878C95Medicare ID - Type Unspecified