Provider Demographics
NPI:1750056586
Name:DR BRYANT KING
Entity Type:Organization
Organization Name:DR BRYANT KING
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:CEO/OWNER/PROVIDER
Authorized Official - Prefix:DR
Authorized Official - First Name:BRYANT
Authorized Official - Middle Name:
Authorized Official - Last Name:KING
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:317-757-9731
Mailing Address - Street 1:3436 KENILWORTH DR
Mailing Address - Street 2:
Mailing Address - City:INDIANAPOLIS
Mailing Address - State:IN
Mailing Address - Zip Code:46228-2703
Mailing Address - Country:US
Mailing Address - Phone:317-757-9731
Mailing Address - Fax:317-983-6295
Practice Address - Street 1:8315 E 56TH ST STE 120
Practice Address - Street 2:
Practice Address - City:INDIANAPOLIS
Practice Address - State:IN
Practice Address - Zip Code:46216-1078
Practice Address - Country:US
Practice Address - Phone:317-757-9731
Practice Address - Fax:317-983-6295
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2021-08-13
Last Update Date:2021-08-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207R00000XAllopathic & Osteopathic PhysiciansInternal MedicineGroup - Multi-Specialty
No207RN0300XAllopathic & Osteopathic PhysiciansInternal MedicineNephrologyGroup - Multi-Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
IN200545640Medicaid
LA1720010341OtherNPPES