Basic Information
| Provider Information | |||||||||
| NPI: | 1114216421 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | KING | ||||||||
| FirstName: | LUCAS | ||||||||
| MiddleName: | RAYMOND | ||||||||
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| Mailing Information | |||||||||
| Address1: | PO BOX 560825 | ||||||||
| Address2: | |||||||||
| City: | DENVER | ||||||||
| State: | CO | ||||||||
| PostalCode: | 802560825 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7195957580 | ||||||||
| FaxNumber: | 7195450176 | ||||||||
| Practice Location | |||||||||
| Address1: | 3676 PARKER BLVD. | ||||||||
| Address2: | STE 310 | ||||||||
| City: | PUEBLO | ||||||||
| State: | CO | ||||||||
| PostalCode: | 810082215 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7195957780 | ||||||||
| FaxNumber: | 7195957789 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 04/07/2011 | ||||||||
| LastUpdateDate: | 07/21/2022 | ||||||||
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| ProviderGenderCode: | M | ||||||||
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| IsSoleProprietor: | N | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 207X00000X | MD.35064 | AL | N | Allopathic & Osteopathic Physicians | Orthopaedic Surgery | 207XX0005X | DR.0058676 | CO | N | Allopathic & Osteopathic Physicians | Orthopaedic Surgery | Sports Medicine | 207X00000X | DR.0058676 | CO | Y | Allopathic & Osteopathic Physicians | Orthopaedic Surgery |
ID Information
| ID | Type | State | Issuer | Description | 9000148102 | 05 | CO | MEDICAID |