Provider Demographics
NPI:1114216421
Name:KING, LUCAS RAYMOND
Entity Type:Individual
Prefix:
First Name:LUCAS
Middle Name:RAYMOND
Last Name:KING
Suffix:
Gender:M
Credentials:
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 560825
Mailing Address - Street 2:
Mailing Address - City:DENVER
Mailing Address - State:CO
Mailing Address - Zip Code:80256-0825
Mailing Address - Country:US
Mailing Address - Phone:719-595-7580
Mailing Address - Fax:719-545-0176
Practice Address - Street 1:3676 PARKER BLVD.
Practice Address - Street 2:STE 310
Practice Address - City:PUEBLO
Practice Address - State:CO
Practice Address - Zip Code:81008-2215
Practice Address - Country:US
Practice Address - Phone:719-595-7780
Practice Address - Fax:719-595-7789
Is Sole Proprietor?:No
Enumeration Date:2011-04-07
Last Update Date:2023-06-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
ALMD.35064207X00000X
CAC185826207X00000X
CODR.0058676207XX0005X, 207X00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207X00000XAllopathic & Osteopathic PhysiciansOrthopaedic Surgery
No207XX0005XAllopathic & Osteopathic PhysiciansOrthopaedic SurgerySports Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
CO9000148102Medicaid