Basic Information
| Provider Information | |||||||||
| NPI: | 1982601381 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | KING | ||||||||
| FirstName: | TERESA | ||||||||
| MiddleName: | MOELLER | ||||||||
| NamePrefix: | DR. | ||||||||
| NameSuffix: | |||||||||
| Credential: | MD | ||||||||
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| Mailing Information | |||||||||
| Address1: | 330 ARKANSAS ST STE 215 | ||||||||
| Address2: | |||||||||
| City: | LAWRENCE | ||||||||
| State: | KS | ||||||||
| PostalCode: | 660441326 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7855052250 | ||||||||
| FaxNumber: | 7855055259 | ||||||||
| Practice Location | |||||||||
| Address1: | 330 ARKANSAS ST STE 215 | ||||||||
| Address2: | |||||||||
| City: | LAWRENCE | ||||||||
| State: | KS | ||||||||
| PostalCode: | 66044 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7855052250 | ||||||||
| FaxNumber: | 7855055259 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 06/30/2005 | ||||||||
| LastUpdateDate: | 12/02/2020 | ||||||||
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| ProviderGenderCode: | F | ||||||||
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| IsSoleProprietor: | Y | ||||||||
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| NPICertificationDate: | 12/02/2020 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 207RG0100X | 0423563 | KS | Y | Allopathic & Osteopathic Physicians | Internal Medicine | Gastroenterology |
ID Information
| ID | Type | State | Issuer | Description | 100127940A | 05 | KS | MEDICAID |