Provider Demographics
NPI:1063455483
Name:KING, BRENT R (MD)
Entity Type:Individual
Prefix:
First Name:BRENT
Middle Name:R
Last Name:KING
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:P.O. BOX 191
Mailing Address - Street 2:
Mailing Address - City:ROCKLAND
Mailing Address - State:DE
Mailing Address - Zip Code:19723-0191
Mailing Address - Country:US
Mailing Address - Phone:302-651-4000
Mailing Address - Fax:302-651-4945
Practice Address - Street 1:1600 ROCKLAND RD
Practice Address - Street 2:
Practice Address - City:WILMINGTON
Practice Address - State:DE
Practice Address - Zip Code:19803-3607
Practice Address - Country:US
Practice Address - Phone:302-651-5860
Practice Address - Fax:302-651-4227
Is Sole Proprietor?:No
Enumeration Date:2006-06-14
Last Update Date:2013-07-25
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TXG5250207P00000X, 207PP0204X, 2080P0204X
DEC10010378207PP0204X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207PP0204XAllopathic & Osteopathic PhysiciansEmergency MedicinePediatric Emergency Medicine
No207P00000XAllopathic & Osteopathic PhysiciansEmergency Medicine
No2080P0204XAllopathic & Osteopathic PhysiciansPediatricsPediatric Emergency Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
TX137016503Medicaid
TX137016510OtherCSHCN
TX82988KOtherBCBS
TX82988KMedicare PIN
TX930076027Medicare PIN
TX137016510OtherCSHCN