Provider Demographics
NPI:1073874657
Name:KING, MIRANDA LYNN (MD)
Entity Type:Individual
Prefix:
First Name:MIRANDA
Middle Name:LYNN
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:PO BOX 3466
Mailing Address - Street 2:
Mailing Address - City:CHARLESTON
Mailing Address - State:WV
Mailing Address - Zip Code:25334-3466
Mailing Address - Country:US
Mailing Address - Phone:304-720-8816
Mailing Address - Fax:
Practice Address - Street 1:2000 MON HEALTH MEDICAL PARK DR STE 2001
Practice Address - Street 2:
Practice Address - City:MORGANTOWN
Practice Address - State:WV
Practice Address - Zip Code:26505
Practice Address - Country:US
Practice Address - Phone:304-720-8816
Practice Address - Fax:904-494-6467
Is Sole Proprietor?:No
Enumeration Date:2012-05-31
Last Update Date:2020-12-30
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI4301100673207L00000X
WV27098207L00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207L00000XAllopathic & Osteopathic PhysiciansAnesthesiology
Provider Identifiers
StateIdentifier IDID TypeIssuer
WV9333201OtherMEDICARE GROUP
WV0207026000OtherGROUP MEDICAID
WV1073874657Medicaid
WVWV6894AMedicare PIN