Provider Demographics
NPI:1881391217
Name:BRYAN, DORRET
Entity type:Individual
Prefix:
First Name:DORRET
Middle Name:
Last Name:BRYAN
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:11 DEVON CT
Mailing Address - Street 2:
Mailing Address - City:NANUET
Mailing Address - State:NY
Mailing Address - Zip Code:10954-3817
Mailing Address - Country:US
Mailing Address - Phone:917-689-1839
Mailing Address - Fax:
Practice Address - Street 1:6143 186TH ST
Practice Address - Street 2:
Practice Address - City:FRESH MEADOWS
Practice Address - State:NY
Practice Address - Zip Code:11365-2710
Practice Address - Country:US
Practice Address - Phone:929-200-7105
Practice Address - Fax:516-324-8785
Is Sole Proprietor?:Yes
Enumeration Date:2023-02-15
Last Update Date:2023-02-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY1258055181174400000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes174400000XOther Service ProvidersSpecialistGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
NYGX97818PMedicaid