Provider Demographics
NPI:1710900642
Name:KING, BRUNETTE MARIE (MD)
Entity Type:Individual
Prefix:
First Name:BRUNETTE
Middle Name:MARIE
Last Name:KING
Suffix:
Gender:F
Credentials:MD
Other - Prefix:
Other - First Name:BRUNETTE
Other - Middle Name:M KING
Other - Last Name:BLUE
Other - Suffix:
Other - Last Name Type:Other Name
Other - Credentials:MD
Mailing Address - Street 1:96 BELMONT CT APT 4
Mailing Address - Street 2:
Mailing Address - City:BROCKTON
Mailing Address - State:MA
Mailing Address - Zip Code:02301-4703
Mailing Address - Country:US
Mailing Address - Phone:337-380-4757
Mailing Address - Fax:
Practice Address - Street 1:516 WEEKS ST
Practice Address - Street 2:BRUNETTE KING BLUE CLINIC APMC
Practice Address - City:NEW IBERIA
Practice Address - State:LA
Practice Address - Zip Code:70560
Practice Address - Country:US
Practice Address - Phone:150-823-2048
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2006-07-25
Last Update Date:2010-11-24
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY121588207LC0200X
LA03634R207LC0200X, 207RC0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207LC0200XAllopathic & Osteopathic PhysiciansAnesthesiologyCritical Care Medicine
No207RC0000XAllopathic & Osteopathic PhysiciansInternal MedicineCardiovascular Disease
Provider Identifiers
StateIdentifier IDID TypeIssuer
LA1192911Medicaid
D79798Medicare UPIN