Healthcare Provider Details

I. General information

NPI: 1073553269
Provider Name (Legal Business Name): BRYAN JACKSON HIKINO BROADBENT MD
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 06/07/2006
Last Update Date: 05/26/2021
Certification Date: 05/26/2021
Deactivation Date:
Reactivation Date:

III. Provider practice location address

7420 MARKET ST
WILMINGTON NC
28411-9453
US

IV. Provider business mailing address

PO BOX 936857
ATLANTA GA
31193-6857
US

V. Phone/Fax

Practice location:
  • Phone: 910-662-6200
  • Fax: 910-686-1606
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207Q00000X
TaxonomyFamily Medicine Physician
License Number35596
License Number StateNC

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: