Provider Demographics
NPI:1770551889
Name:KING, BRODERICK DARYL (MD)
Entity type:Individual
Prefix:
First Name:BRODERICK
Middle Name:DARYL
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 1:101 AUBREYS LOOP
Mailing Address - Street 2:
Mailing Address - City:SOUTH BOSTON
Mailing Address - State:VA
Mailing Address - Zip Code:24592-5056
Mailing Address - Country:US
Mailing Address - Phone:434-517-3879
Mailing Address - Fax:434-517-3989
Practice Address - Street 1:101 AUBREYS LOOP
Practice Address - Street 2:
Practice Address - City:SOUTH BOSTON
Practice Address - State:VA
Practice Address - Zip Code:24592-5056
Practice Address - Country:US
Practice Address - Phone:434-517-3879
Practice Address - Fax:434-517-3989
Is Sole Proprietor?:No
Enumeration Date:2006-03-14
Last Update Date:2012-12-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
VA0101234095207R00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207R00000XAllopathic & Osteopathic PhysiciansInternal Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
VA288916OtherBCBS
VA005882451Medicaid
VA62491OtherOPTIMA
VA288916OtherBCBS
VA005882451Medicaid