Basic Information
| Provider Information | |||||||||
| NPI: | 1306039276 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | KING | ||||||||
| FirstName: | DAVID | ||||||||
| MiddleName: | MICHAEL | ||||||||
| NamePrefix: | |||||||||
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| Credential: | D.O. | ||||||||
| OtherOrganizationName: | |||||||||
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| Mailing Information | |||||||||
| Address1: | 901 W ALAMEDA ST | ||||||||
| Address2: | STE 25 | ||||||||
| City: | SANTA FE | ||||||||
| State: | NM | ||||||||
| PostalCode: | 875011673 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 5059888869 | ||||||||
| FaxNumber: | 5059826298 | ||||||||
| Practice Location | |||||||||
| Address1: | 901 W ALAMEDA ST STE 25 | ||||||||
| Address2: | |||||||||
| City: | SANTA FE | ||||||||
| State: | NM | ||||||||
| PostalCode: | 875011673 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 5059888869 | ||||||||
| FaxNumber: | 5059826298 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 08/23/2007 | ||||||||
| LastUpdateDate: | 03/02/2021 | ||||||||
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| ProviderGenderCode: | M | ||||||||
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| IsSoleProprietor: | N | ||||||||
| IsOrganizationSubpart: | |||||||||
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| NPICertificationDate: | 03/02/2021 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 208000000X | 4370 | OK | Y | Allopathic & Osteopathic Physicians | Pediatrics |
ID Information
| ID | Type | State | Issuer | Description | 200122440B | 05 | OK | MEDICAID |