1730266032 NPI number — DR. GLENDA L. KING DPM

Table of content: DR. GLENDA L. KING DPM (NPI 1730266032)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1730266032 NPI number — DR. GLENDA L. KING DPM

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
Provider Last Name:
KING
Provider First Name:
GLENDA
Provider Middle Name:
L.
Provider Name Prefix Text:
DR.
Provider Name Suffix Text:
Provider Credential Text:
DPM
Provider Gender Code:
F

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:
1730266032
Entity Type Code:
Individual
Replacement NPI:
Last Update Date:
06/14/2015
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
2019 GALISTEO ST
Provider Second Line Business Mailing Address:
UNIT A4
Provider Business Mailing Address City Name:
SANTA FE
Provider Business Mailing Address State Name:
NM
Provider Business Mailing Address Postal Code:
87505-2143
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
505-988-3338
Provider Business Mailing Address Fax Number:
505-982-3668

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
2019 GALISTEO ST
Provider Second Line Business Practice Location Address:
UNIT A4
Provider Business Practice Location Address City Name:
SANTA FE
Provider Business Practice Location Address State Name:
NM
Provider Business Practice Location Address Postal Code:
87505-2143
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
505-988-3338
Provider Business Practice Location Address Fax Number:
505-982-3668
Provider Enumeration Date:
11/01/2006

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: 213ES0103X , with the licence number:  NM296 , registered in the state of NM ; information, associated with the NPI states the following Primary Taxonomy Switch: "N" .
  • Taxonomy code: 213E00000X , with the licence number: NM296 , registered in the state of NM ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

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

  • Identifier: 85207578 . This is a "MCAID GROUP" identifier , issued by the state of ( NM ) . This identifiers is of the category "OTHER".
  • Identifier: NMB2387 . This is a "MCARE GROUP PIN" identifier , issued by the state of ( NM ) . This identifiers is of the category "OTHER".
  • Identifier: 1093042632 . This is a "GROUP NPI # FOR CORPORATION" identifier , issued by the state of ( NM ) . This identifiers is of the category "OTHER".
  • Identifier: 9558062 . This is a "AETNA" identifier , issued by the state of ( NM ) . This identifiers is of the category "OTHER".
  • Identifier: DR8662 . This is a "RR MCARE GRP PIN" identifier , issued by the state of ( NM ) . This identifiers is of the category "OTHER".
  • Identifier: 4781043 . This is a "CIGNA" identifier , issued by the state of ( NM ) . This identifiers is of the category "OTHER".
  • Identifier: NM296 . This is a "MEDICAL LICENSE #" identifier , issued by the state of ( NM ) . This identifiers is of the category "OTHER".
  • Identifier: 01331752 . This is a "AMERIGROUP" identifier , issued by the state of ( NM ) . This identifiers is of the category "OTHER".
  • Identifier: P00972986 . This is a "RR MCARE IND PIN" identifier , issued by the state of ( NM ) . This identifiers is of the category "OTHER".
  • Identifier: 22952039 , issued by the state of ( NM ) . This identifiers is of the category "MEDICAID".




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