Basic Information
| Provider Information | |||||||||
| NPI: | 1457441586 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | KING | ||||||||
| FirstName: | MAGGIE | ||||||||
| MiddleName: | J | ||||||||
| NamePrefix: | |||||||||
| NameSuffix: | |||||||||
| Credential: | MD | ||||||||
| OtherOrganizationName: | |||||||||
| OtherOrganizationType: | |||||||||
| OtherLastName: | CROSS | ||||||||
| OtherFirstName: | MAGGIE | ||||||||
| OtherMiddleName: | J | ||||||||
| OtherNamePrefix: | |||||||||
| OtherNameSuffix: | |||||||||
| OtherCredential: | MD | ||||||||
| OtherLastNameType: | 1 | ||||||||
| Mailing Information | |||||||||
| Address1: | PO BOX 7287 | ||||||||
| Address2: | |||||||||
| City: | BEND | ||||||||
| State: | OR | ||||||||
| PostalCode: | 977087287 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 5414476263 | ||||||||
| FaxNumber: | 5414474698 | ||||||||
| Practice Location | |||||||||
| Address1: | 384 SE COMBS FLAT RD STE 1200 | ||||||||
| Address2: | |||||||||
| City: | PRINEVILLE | ||||||||
| State: | OR | ||||||||
| PostalCode: | 977542562 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 5414476263 | ||||||||
| FaxNumber: | 5414478475 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 10/12/2006 | ||||||||
| LastUpdateDate: | 04/16/2020 | ||||||||
| NPIDeactivationReasonCode: | |||||||||
| NPIDeactivationDate: | |||||||||
| NPIReactivationDate: | |||||||||
| ProviderGenderCode: | F | ||||||||
| AuthorizedOfficialLastName: | |||||||||
| AuthorizedOfficialFirstName: | |||||||||
| AuthorizedOfficialMiddleName: | |||||||||
| AuthorizedOfficialTitleorPosition: | |||||||||
| AuthorizedOfficialTelephone: | |||||||||
| IsSoleProprietor: | Y | ||||||||
| IsOrganizationSubpart: | |||||||||
| ParentOrganizationLBN: | |||||||||
| AuthorizedOfficialNamePrefix: | |||||||||
| AuthorizedOfficialNameSuffix: | |||||||||
| AuthorizedOfficialCredential: | |||||||||
| NPICertificationDate: | 04/16/2020 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 207Q00000X | MD26910 | OR | Y | Allopathic & Osteopathic Physicians | Family Medicine |
ID Information
| ID | Type | State | Issuer | Description | MD26910 | 01 | OR | LICENSE | OTHER |