Provider Demographics
NPI:1720010341
Name:KING, BRYANT ALAN (MD)
Entity type:Individual
Prefix:
First Name:BRYANT
Middle Name:ALAN
Last Name:KING
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
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Other - Credentials:
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:317-291-0640
Practice Address - Street 1:3436 KENILWORTH DR
Practice Address - Street 2:
Practice Address - City:INDIANAPOLIS
Practice Address - State:IN
Practice Address - Zip Code:46228-2703
Practice Address - Country:US
Practice Address - Phone:317-757-9731
Practice Address - Fax:317-291-0640
Is Sole Proprietor?:No
Enumeration Date:2006-07-06
Last Update Date:2019-08-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IN01061402A207RN0300X, 207R00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207R00000XAllopathic & Osteopathic PhysiciansInternal Medicine
No207RN0300XAllopathic & Osteopathic PhysiciansInternal MedicineNephrology
Provider Identifiers
StateIdentifier IDID TypeIssuer
IN200545640Medicaid
H80627Medicare UPIN
IN200545640Medicaid
IN796270PPMedicare PIN