Basic Information
| Provider Information | |||||||||
| NPI: | 1639118367 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | KING | ||||||||
| FirstName: | BRADLEY | ||||||||
| MiddleName: | OWEN | ||||||||
| NamePrefix: | DR. | ||||||||
| NameSuffix: | |||||||||
| Credential: | MD | ||||||||
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| Mailing Information | |||||||||
| Address1: | 1000 S BECKHAM AVE | ||||||||
| Address2: | |||||||||
| City: | TYLER | ||||||||
| State: | TX | ||||||||
| PostalCode: | 757011908 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 9035970351 | ||||||||
| FaxNumber: | 9035259301 | ||||||||
| Practice Location | |||||||||
| Address1: | 1000 S BECKHAM AVE | ||||||||
| Address2: | |||||||||
| City: | TYLER | ||||||||
| State: | TX | ||||||||
| PostalCode: | 757011908 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 9035970351 | ||||||||
| FaxNumber: | 9035259301 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 06/06/2006 | ||||||||
| LastUpdateDate: | 07/09/2014 | ||||||||
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| ProviderGenderCode: | M | ||||||||
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| IsSoleProprietor: | N | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 207P00000X | L0336 | TX | Y | Allopathic & Osteopathic Physicians | Emergency Medicine |
ID Information
| ID | Type | State | Issuer | Description | 0372286-04 | 05 | TX | MEDICAID | 930120767 | 01 | TX | RAILROAD MEDICARE | OTHER | 8F6462 | 01 | TX | BLUE CROSS | OTHER |