Provider Demographics
NPI:1063476190
Name:KING, STEPHANIE ANGELA (MD)
Entity Type:Individual
Prefix:
First Name:STEPHANIE
Middle Name:ANGELA
Last Name:KING
Suffix:
Gender:F
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2450 W HUNTING PARK AVE
Mailing Address - Street 2:
Mailing Address - City:PHILADELPHIA
Mailing Address - State:PA
Mailing Address - Zip Code:19129-1302
Mailing Address - Country:US
Mailing Address - Phone:215-728-6900
Mailing Address - Fax:215-255-7825
Practice Address - Street 1:333 COTTMAN AVENUE
Practice Address - Street 2:FOX CHASE CANCER CENTER
Practice Address - City:PHILADELPHIA
Practice Address - State:PA
Practice Address - Zip Code:19111
Practice Address - Country:US
Practice Address - Phone:215-728-6900
Practice Address - Fax:215-762-4323
Is Sole Proprietor?:No
Enumeration Date:2006-04-14
Last Update Date:2018-04-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
PAMD033507E207V00000X, 207VX0201X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207VX0201XAllopathic & Osteopathic PhysiciansObstetrics & GynecologyGynecologic Oncology
No207V00000XAllopathic & Osteopathic PhysiciansObstetrics & Gynecology
Provider Identifiers
StateIdentifier IDID TypeIssuer
PA0011249890006Medicaid
PA001124989Medicaid
PA605266Medicare ID - Type Unspecified
PA001124989Medicaid
PA0011249890006Medicaid