Provider Demographics
NPI:1073553269
Name:BROADBENT, BRYAN JACKSON HIKINO (MD)
Entity Type:Individual
Prefix:
First Name:BRYAN
Middle Name:JACKSON HIKINO
Last Name:BROADBENT
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:PO BOX 936857
Mailing Address - Street 2:
Mailing Address - City:ATLANTA
Mailing Address - State:GA
Mailing Address - Zip Code:31193-6857
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:7420 MARKET ST
Practice Address - Street 2:
Practice Address - City:WILMINGTON
Practice Address - State:NC
Practice Address - Zip Code:28411-9453
Practice Address - Country:US
Practice Address - Phone:910-662-6200
Practice Address - Fax:910-686-1606
Is Sole Proprietor?:No
Enumeration Date:2006-06-07
Last Update Date:2021-05-26
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NC35596207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
NC7918540Medicaid
NC1073553269Medicaid
NC7918540Medicaid
NC2192374CMedicare PIN
NC080084958Medicare PIN
NC2192374BMedicare PIN
NC1073553269Medicaid