Basic Information
| Provider Information | |||||||||
| NPI: | 1851337059 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | KING | ||||||||
| FirstName: | RICKEY | ||||||||
| MiddleName: | DUWAYNE | ||||||||
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| Credential: | MD | ||||||||
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| Mailing Information | |||||||||
| Address1: | PO BOX 4749 | ||||||||
| Address2: | |||||||||
| City: | MEDFORD | ||||||||
| State: | OR | ||||||||
| PostalCode: | 975010227 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 5417895516 | ||||||||
| FaxNumber: | 5417895538 | ||||||||
| Practice Location | |||||||||
| Address1: | 280 MAPLE ST | ||||||||
| Address2: | |||||||||
| City: | ASHLAND | ||||||||
| State: | OR | ||||||||
| PostalCode: | 975201552 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 5412014000 | ||||||||
| FaxNumber: | 2539447922 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 06/22/2006 | ||||||||
| LastUpdateDate: | 07/28/2014 | ||||||||
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| ProviderGenderCode: | M | ||||||||
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| IsSoleProprietor: | N | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 207P00000X | MD00039954 | WA | N | Allopathic & Osteopathic Physicians | Emergency Medicine | 207P00000X | MD150570 | OR | Y | Allopathic & Osteopathic Physicians | Emergency Medicine |
ID Information
| ID | Type | State | Issuer | Description | 4968KI | 01 | WA | BSWA | OTHER | 8283921 | 05 | WA | MEDICAID | 0170820 | 01 | WA | LIWA | OTHER | 0170830 | 01 | WA | LIWA | OTHER | 1186KI | 01 | WA | BSWA | OTHER |