Provider Demographics
NPI:1194735670
Name:KING, BRYAN C (MD)
Entity type:Individual
Prefix:
First Name:BRYAN
Middle Name:C
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 1:1300 N 500 E
Mailing Address - Street 2:#130
Mailing Address - City:LOGAN
Mailing Address - State:UT
Mailing Address - Zip Code:84341-2408
Mailing Address - Country:US
Mailing Address - Phone:435-716-2800
Mailing Address - Fax:
Practice Address - Street 1:1300 N 500 E
Practice Address - Street 2:#130
Practice Address - City:LOGAN
Practice Address - State:UT
Practice Address - Zip Code:84341-2408
Practice Address - Country:US
Practice Address - Phone:435-716-2800
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2006-08-08
Last Update Date:2008-08-04
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
UT50803121205207X00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207X00000XAllopathic & Osteopathic PhysiciansOrthopaedic Surgery
Provider Identifiers
StateIdentifier IDID TypeIssuer
UTH57801Medicare UPIN
UT000063358Medicare PIN