Provider Demographics
NPI:1073537239
Name:KING, MICHAEL LEE (MD)
Entity Type:Individual
Prefix:
First Name:MICHAEL
Middle Name:LEE
Last Name:KING
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1600 N GRAND AVE
Mailing Address - Street 2:STE 510
Mailing Address - City:PUEBLO
Mailing Address - State:CO
Mailing Address - Zip Code:81003-2700
Mailing Address - Country:US
Mailing Address - Phone:719-566-3535
Mailing Address - Fax:719-566-3565
Practice Address - Street 1:1600 N GRAND AVE
Practice Address - Street 2:STE 510
Practice Address - City:PUEBLO
Practice Address - State:CO
Practice Address - Zip Code:81003-2700
Practice Address - Country:US
Practice Address - Phone:719-566-3535
Practice Address - Fax:719-566-3565
Is Sole Proprietor?:No
Enumeration Date:2006-07-27
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CO28090208600000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208600000XAllopathic & Osteopathic PhysiciansSurgery
Provider Identifiers
StateIdentifier IDID TypeIssuer
CO01280908Medicaid
CO01280908Medicaid
391528Medicare ID - Type Unspecified