1417049396 NPI number — DR. DAVID MARK KING M.D.

Table of content: DR. DAVID MARK KING M.D. (NPI 1417049396)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1417049396 NPI number — DR. DAVID MARK KING M.D.

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
Provider Last Name:
KING
Provider First Name:
DAVID
Provider Middle Name:
MARK
Provider Name Prefix Text:
DR.
Provider Name Suffix Text:
Provider Credential Text:
M.D.
Provider Gender Code:
M

Provider's Other Name Information

Provider Other Organization Name:
Provider Other Organization Name Type Code:
Provider Other Last Name:
Provider Other First Name:
Provider Other Middle Name:
Provider Other Name Prefix Text:
Provider Other Name Suffix Text:
Provider Other Credential Text:
Provider Other Last Name Type Code:

NPI Number Information

NPI Number:
1417049396
Entity Type Code:
Individual
Replacement NPI:
Last Update Date:
02/21/2018
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
2550 UNIVERSITY AVE W STE 110N
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
SAINT PAUL
Provider Business Mailing Address State Name:
MN
Provider Business Mailing Address Postal Code:
55114-2001
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
651-602-5309
Provider Business Mailing Address Fax Number:
651-222-6786

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
480 OSBORNE RD NE
Provider Second Line Business Practice Location Address:
SUITE 220
Provider Business Practice Location Address City Name:
FRIDLEY
Provider Business Practice Location Address State Name:
MN
Provider Business Practice Location Address Postal Code:
55432-2281
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
763-786-1620
Provider Business Practice Location Address Fax Number:
763-780-3099
Provider Enumeration Date:
09/29/2006

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: 207RX0202X , with the licence number:  45762 , registered in the state of MN ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

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

  • Identifier: PREFERRED ONE . This is a "963001035165" identifier , issued by the state of ( MN ) . This identifiers is of the category "OTHER".
  • Identifier: 369232900 , issued by the state of ( MN ) . This identifiers is of the category "MEDICAID".
  • Identifier: MEDICA . This is a "3600374" identifier , issued by the state of ( MN ) . This identifiers is of the category "OTHER".
  • Identifier: SELECT CARE . This is a "3600374" identifier , issued by the state of ( MN ) . This identifiers is of the category "OTHER".
  • Identifier: 171840 . This is a "UCARE" identifier , issued by the state of ( MN ) . This identifiers is of the category "OTHER".
  • Identifier: BLUE CROSS . This is a "043G4KI" identifier , issued by the state of ( MN ) . This identifiers is of the category "OTHER".
  • Identifier: HEALTH PARTNERS . This is a "HP39070" identifier , issued by the state of ( MN ) . This identifiers is of the category "OTHER".
  • Identifier: COMMERCIAL . This is a "410729979" identifier , issued by the state of ( MN ) . This identifiers is of the category "OTHER".




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