Basic Information
| Provider Information | |||||||||
| NPI: | 1164439451 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | KING | ||||||||
| FirstName: | LISA | ||||||||
| MiddleName: | |||||||||
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| Credential: | M.D. | ||||||||
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| Mailing Information | |||||||||
| Address1: | 6801 DIXIE HWY | ||||||||
| Address2: | SUITE 130 | ||||||||
| City: | LOUISVILLE | ||||||||
| State: | KY | ||||||||
| PostalCode: | 402583913 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 5029686226 | ||||||||
| FaxNumber: | 5029665562 | ||||||||
| Practice Location | |||||||||
| Address1: | 5100 OUTER LOOP | ||||||||
| Address2: | |||||||||
| City: | LOUISVILLE | ||||||||
| State: | KY | ||||||||
| PostalCode: | 402194056 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 5029686226 | ||||||||
| FaxNumber: | 5029665562 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 08/01/2006 | ||||||||
| LastUpdateDate: | 07/29/2013 | ||||||||
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| ProviderGenderCode: | F | ||||||||
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| IsSoleProprietor: | N | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 207Q00000X | 45295 | KY | Y | Allopathic & Osteopathic Physicians | Family Medicine |
ID Information
| ID | Type | State | Issuer | Description | 7100203510 | 05 | KY | MEDICAID | 2731509-00 | 05 | FL | MEDICAID |