Provider Demographics
NPI:1265639892
Name:LISA KING MD LLC
Entity Type:Organization
Organization Name:LISA KING MD LLC
Other - Org Name:WELLNESS MEDICAL CENTER
Other - Org Type:Doing Business As
Authorized Official - Title/Position:PHYSICIAN OWNER
Authorized Official - Prefix:DR
Authorized Official - First Name:LISA
Authorized Official - Middle Name:
Authorized Official - Last Name:KING
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:540-785-9500
Mailing Address - Street 1:10514 WAKEMAN DR
Mailing Address - Street 2:
Mailing Address - City:FREDERICKSBURG
Mailing Address - State:VA
Mailing Address - Zip Code:22407-8040
Mailing Address - Country:US
Mailing Address - Phone:540-785-9500
Mailing Address - Fax:866-601-0609
Practice Address - Street 1:10514 WAKEMAN DR
Practice Address - Street 2:
Practice Address - City:FREDERICKSBURG
Practice Address - State:VA
Practice Address - Zip Code:22407-8040
Practice Address - Country:US
Practice Address - Phone:540-785-9500
Practice Address - Fax:866-601-0609
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-06-28
Last Update Date:2012-03-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207R00000XAllopathic & Osteopathic PhysiciansInternal MedicineGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
C10275Medicare PIN