Provider Demographics
NPI:1104860287
Name:KING, ALICIA D (DO)
Entity Type:Individual
Prefix:
First Name:ALICIA
Middle Name:D
Last Name:KING
Suffix:
Gender:F
Credentials:DO
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:172 PROFESSIONAL PKWY
Mailing Address - Street 2:
Mailing Address - City:TROY
Mailing Address - State:MO
Mailing Address - Zip Code:63379-2823
Mailing Address - Country:US
Mailing Address - Phone:636-462-6106
Mailing Address - Fax:
Practice Address - Street 1:172 PROFESSIONAL PKWY
Practice Address - Street 2:
Practice Address - City:TROY
Practice Address - State:MO
Practice Address - Zip Code:63379-2823
Practice Address - Country:US
Practice Address - Phone:636-462-6106
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2006-06-16
Last Update Date:2009-12-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
KS0532427207Q00000X
MO2006006975207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
I51444Medicare UPIN