Basic Information
| Provider Information | |||||||||
| NPI: | 1407899545 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | KING | ||||||||
| FirstName: | CLIFFORD | ||||||||
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| Credential: | MD | ||||||||
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| Mailing Information | |||||||||
| Address1: | 1808 W BELTLINE HWY | ||||||||
| Address2: | |||||||||
| City: | MADISON | ||||||||
| State: | WI | ||||||||
| PostalCode: | 537132334 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 6082501497 | ||||||||
| FaxNumber: | 6082501384 | ||||||||
| Practice Location | |||||||||
| Address1: | 2275 DEMING WAY STE 240 | ||||||||
| Address2: | |||||||||
| City: | MIDDLETON | ||||||||
| State: | WI | ||||||||
| PostalCode: | 535625527 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 6088214020 | ||||||||
| FaxNumber: | 6088214040 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 06/14/2006 | ||||||||
| LastUpdateDate: | 11/30/2020 | ||||||||
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| ProviderGenderCode: | M | ||||||||
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| IsSoleProprietor: | N | ||||||||
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| NPICertificationDate: | 11/30/2020 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 2086S0122X | 38474-020 | WI | Y | Allopathic & Osteopathic Physicians | Surgery | Plastic and Reconstructive Surgery |
ID Information
| ID | Type | State | Issuer | Description | 1407899545 | 05 | WI | MEDICAID |