Basic Information
| Provider Information | |||||||||
| NPI: | 1518346717 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | KING | ||||||||
| FirstName: | KRISTIN | ||||||||
| MiddleName: | HEATHER | ||||||||
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| Credential: | MD | ||||||||
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| Mailing Information | |||||||||
| Address1: | 300 HILLMONT AVE | ||||||||
| Address2: | |||||||||
| City: | VENTURA | ||||||||
| State: | CA | ||||||||
| PostalCode: | 930031651 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8056526100 | ||||||||
| FaxNumber: | 8056523252 | ||||||||
| Practice Location | |||||||||
| Address1: | 300 HILLMONT AVE | ||||||||
| Address2: | |||||||||
| City: | VENTURA | ||||||||
| State: | CA | ||||||||
| PostalCode: | 93003 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8056526556 | ||||||||
| FaxNumber: | |||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 05/21/2015 | ||||||||
| LastUpdateDate: | 06/17/2021 | ||||||||
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| ProviderGenderCode: | F | ||||||||
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| IsSoleProprietor: | N | ||||||||
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| NPICertificationDate: | 06/17/2021 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 390200000X | N | Student, Health Care | Student in an Organized Health Care Education/Training Program | 207Q00000X | MD-19704 | HI | Y | Allopathic & Osteopathic Physicians | Family Medicine | 207Q00000X | A145288 | CA | N | Allopathic & Osteopathic Physicians | Family Medicine |
No ID Information.