Provider Demographics
NPI:1639118367
Name:KING, BRADLEY OWEN (MD)
Entity Type:Individual
Prefix:DR
First Name:BRADLEY
Middle Name:OWEN
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 1:1000 S BECKHAM AVE
Mailing Address - Street 2:
Mailing Address - City:TYLER
Mailing Address - State:TX
Mailing Address - Zip Code:75701-1908
Mailing Address - Country:US
Mailing Address - Phone:903-597-0351
Mailing Address - Fax:903-525-9301
Practice Address - Street 1:1000 S BECKHAM AVE
Practice Address - Street 2:
Practice Address - City:TYLER
Practice Address - State:TX
Practice Address - Zip Code:75701-1908
Practice Address - Country:US
Practice Address - Phone:903-597-0351
Practice Address - Fax:903-525-9301
Is Sole Proprietor?:No
Enumeration Date:2006-06-06
Last Update Date:2014-07-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TXL0336207P00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207P00000XAllopathic & Osteopathic PhysiciansEmergency Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
TX0372286-04Medicaid
TX930120767OtherRAILROAD MEDICARE
TX8F6462OtherBLUE CROSS
TX349638YLLYMedicare PIN
TX349638YKN5Medicare PIN
TX0372286-04Medicaid
TX930120767OtherRAILROAD MEDICARE
TX8831B6Medicare PIN