Basic Information
| Provider Information | |||||||||
| NPI: | 1770551889 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | KING | ||||||||
| FirstName: | BRODERICK | ||||||||
| MiddleName: | DARYL | ||||||||
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| NameSuffix: | |||||||||
| Credential: | MD | ||||||||
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| Mailing Information | |||||||||
| Address1: | 101 AUBREYS LOOP | ||||||||
| Address2: | |||||||||
| City: | SOUTH BOSTON | ||||||||
| State: | VA | ||||||||
| PostalCode: | 245925056 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 4345173879 | ||||||||
| FaxNumber: | 4345173989 | ||||||||
| Practice Location | |||||||||
| Address1: | 101 AUBREYS LOOP | ||||||||
| Address2: | |||||||||
| City: | SOUTH BOSTON | ||||||||
| State: | VA | ||||||||
| PostalCode: | 245925056 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 4345173879 | ||||||||
| FaxNumber: | 4345173989 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 03/14/2006 | ||||||||
| LastUpdateDate: | 12/27/2012 | ||||||||
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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 | 207R00000X | 0101234095 | VA | Y | Allopathic & Osteopathic Physicians | Internal Medicine |
ID Information
| ID | Type | State | Issuer | Description | 288916 | 01 | VA | BCBS | OTHER | 005882451 | 05 | VA | MEDICAID | 62491 | 01 | VA | OPTIMA | OTHER |