Provider Demographics
NPI:1114998606
Name:KING, KELLY ENNIX (MD)
Entity Type:Individual
Prefix:DR
First Name:KELLY
Middle Name:ENNIX
Last Name:KING
Suffix:
Gender:F
Credentials:MD
Other - Prefix:DR
Other - First Name:KELLY
Other - Middle Name:SHERWOOD
Other - Last Name:ENNIX
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:MD
Mailing Address - Street 1:11113 COVENTRY GROVE CIR
Mailing Address - Street 2:
Mailing Address - City:LITHIA
Mailing Address - State:FL
Mailing Address - Zip Code:33547-4924
Mailing Address - Country:US
Mailing Address - Phone:813-244-4741
Mailing Address - Fax:
Practice Address - Street 1:935 OAKFIELD DR
Practice Address - Street 2:
Practice Address - City:BRANDON
Practice Address - State:FL
Practice Address - Zip Code:33511-4935
Practice Address - Country:US
Practice Address - Phone:813-651-3492
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2006-02-01
Last Update Date:2023-05-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLME116572207R00000X, 208M00000X
CAA83650207R00000X, 208M00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208M00000XAllopathic & Osteopathic PhysiciansHospitalist
No207R00000XAllopathic & Osteopathic PhysiciansInternal Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
CA009385100Medicaid
FL009385100Medicaid