Healthcare Provider Details

I. General information

NPI: 1710900642
Provider Name (Legal Business Name): BRUNETTE MARIE KING MD
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

Provider Other Name: BRUNETTE M. KING BLUE M.D.

II. Dates (important events)

Enumeration Date: 07/25/2006
Last Update Date: 11/24/2010
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

516 WEEKS ST BRUNETTE KING BLUE CLINIC APMC
NEW IBERIA LA
70560
US

IV. Provider business mailing address

96 BELMONT CT APT 4
BROCKTON MA
02301-4703
US

V. Phone/Fax

Practice location:
  • Phone: 150-823-2048
  • Fax:
Mailing address:
  • Phone: 337-380-4757
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207LC0200X
TaxonomyCritical Care Medicine (Anesthesiology) Physician
License Number121588
License Number StateNY
# 2
Primary TaxonomyN
Taxonomy Code207LC0200X
TaxonomyCritical Care Medicine (Anesthesiology) Physician
License Number03634R
License Number StateLA
# 3
Primary TaxonomyN
Taxonomy Code207RC0000X
TaxonomyCardiovascular Disease Physician
License Number03634R
License Number StateLA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: