Provider Demographics
NPI:1164549382
Name:KING, OSRIC SHAUN (MD)
Entity Type:Individual
Prefix:DR
First Name:OSRIC
Middle Name:SHAUN
Last Name:KING
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:17660 UNION TPKE
Mailing Address - Street 2:SUITE #190
Mailing Address - City:FRESH MEADOWS
Mailing Address - State:NY
Mailing Address - Zip Code:11366-1531
Mailing Address - Country:US
Mailing Address - Phone:718-591-5693
Mailing Address - Fax:718-591-8919
Practice Address - Street 1:17660 UNION TPKE
Practice Address - Street 2:SUITE #190
Practice Address - City:FRESH MEADOWS
Practice Address - State:NY
Practice Address - Zip Code:11366-1531
Practice Address - Country:US
Practice Address - Phone:718-591-5693
Practice Address - Fax:718-591-8919
Is Sole Proprietor?:Yes
Enumeration Date:2007-03-23
Last Update Date:2021-04-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY206390174400000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes174400000XOther Service ProvidersSpecialist
Provider Identifiers
StateIdentifier IDID TypeIssuer
NY5005A1OtherBLUE CROSS BLUE SHIELDS
NY043604737Other2ND GHI
NY2778049OtherAETNA HMO
NY043604737OtherTAX IDENTIFICATION NUMBER
NY7226057OtherAETNA PPO
NY9684750OtherGHI
NYP2695786OtherOXFORD FREEDOM
NYP2695786OtherOXFORD FREEDOM
NY043604737OtherTAX IDENTIFICATION NUMBER