Provider Demographics
NPI:1164439451
Name:KING, LISA (MD)
Entity Type:Individual
Prefix:
First Name:LISA
Middle Name:
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 1:6801 DIXIE HWY
Mailing Address - Street 2:SUITE 130
Mailing Address - City:LOUISVILLE
Mailing Address - State:KY
Mailing Address - Zip Code:40258-3913
Mailing Address - Country:US
Mailing Address - Phone:502-968-6226
Mailing Address - Fax:502-966-5562
Practice Address - Street 1:5100 OUTER LOOP
Practice Address - Street 2:
Practice Address - City:LOUISVILLE
Practice Address - State:KY
Practice Address - Zip Code:40219-4056
Practice Address - Country:US
Practice Address - Phone:502-968-6226
Practice Address - Fax:502-966-5562
Is Sole Proprietor?:No
Enumeration Date:2006-08-01
Last Update Date:2013-07-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
KY45295207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
KY7100203510Medicaid
FL2731509-00Medicaid
FL2731509-00Medicaid
FL16364ZMedicare ID - Type Unspecified
KYK042470Medicare PIN
FLH17527Medicare UPIN