Provider Demographics
NPI:1922051705
Name:MAGGARD, BRIAN L (MD)
Entity Type:Individual
Prefix:DR
First Name:BRIAN
Middle Name:L
Last Name:MAGGARD
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 1:2070 KING COLLEGE RD
Mailing Address - Street 2:
Mailing Address - City:BRISTOL
Mailing Address - State:TN
Mailing Address - Zip Code:37620-2920
Mailing Address - Country:US
Mailing Address - Phone:276-202-8632
Mailing Address - Fax:
Practice Address - Street 1:3550 HIGHWAY 75
Practice Address - Street 2:
Practice Address - City:KINGSPORT
Practice Address - State:TN
Practice Address - Zip Code:37663-4031
Practice Address - Country:US
Practice Address - Phone:423-328-8833
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2006-05-19
Last Update Date:2023-08-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
VA0101058365207Q00000X, 2083A0300X
TN312362083A0300X
TNMD31236207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
No2083A0300XAllopathic & Osteopathic PhysiciansPreventive MedicineAddiction Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
VA1922051705Medicaid
TN1513226Medicaid