1821083676 NPI number — FREDERICK DOUGLAS KING II PHD PT

Table of content: FREDERICK DOUGLAS KING II PHD PT (NPI 1821083676)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1821083676 NPI number — FREDERICK DOUGLAS KING II PHD PT

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
Provider Last Name:
KING
Provider First Name:
FREDERICK
Provider Middle Name:
DOUGLAS
Provider Name Prefix Text:
Provider Name Suffix Text:
II
Provider Credential Text:
PHD PT
Provider Gender Code:
M

Provider's Other Name Information

Provider Other Organization Name:
Provider Other Organization Name Type Code:
Provider Other Last Name:
KING
Provider Other First Name:
FRED
Provider Other Middle Name:
D
Provider Other Name Prefix Text:
MR.
Provider Other Name Suffix Text:
II
Provider Other Credential Text:
PHD PT
Provider Other Last Name Type Code:
5

NPI Number Information

NPI Number:
1821083676
Entity Type Code:
Individual
Replacement NPI:
Last Update Date:
07/08/2007
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
2486 N PONDEROSA DR
Provider Second Line Business Mailing Address:
STE D106
Provider Business Mailing Address City Name:
CAMARILLO
Provider Business Mailing Address State Name:
CA
Provider Business Mailing Address Postal Code:
93010-2376
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
805-484-5447
Provider Business Mailing Address Fax Number:
805-484-2158

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
2486 N PONDEROSA DR
Provider Second Line Business Practice Location Address:
STE D106
Provider Business Practice Location Address City Name:
CAMARILLO
Provider Business Practice Location Address State Name:
CA
Provider Business Practice Location Address Postal Code:
93010-2376
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
805-484-5447
Provider Business Practice Location Address Fax Number:
805-484-2158
Provider Enumeration Date:
09/19/2005

Additional Information

Authorized Official

Authorized Official Last Name:
Authorized Official First Name:
Authorized Official Middle Name:
Authorized Official Title or Position:
Authorized Official Telephone Number:

Provider Taxonomy Codes

  • Taxonomy code: 225100000X , with the licence number:  PT005390 , registered in the state of CA ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

Other Provider's Identifiers (legacy, non-NPI)





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