Provider Demographics
NPI:1407899545
Name:KING, CLIFFORD (MD)
Entity Type:Individual
Prefix:
First Name:CLIFFORD
Middle Name:
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 1:1808 W BELTLINE HWY
Mailing Address - Street 2:
Mailing Address - City:MADISON
Mailing Address - State:WI
Mailing Address - Zip Code:53713-2334
Mailing Address - Country:US
Mailing Address - Phone:608-250-1497
Mailing Address - Fax:608-250-1384
Practice Address - Street 1:2275 DEMING WAY STE 240
Practice Address - Street 2:
Practice Address - City:MIDDLETON
Practice Address - State:WI
Practice Address - Zip Code:53562-5527
Practice Address - Country:US
Practice Address - Phone:608-821-4020
Practice Address - Fax:608-821-4040
Is Sole Proprietor?:No
Enumeration Date:2006-06-14
Last Update Date:2020-11-30
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WI38474-0202086S0122X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2086S0122XAllopathic & Osteopathic PhysiciansSurgeryPlastic and Reconstructive Surgery
Provider Identifiers
StateIdentifier IDID TypeIssuer
WI1407899545Medicaid
WI32367600Medicaid
WI32367600Medicaid
WI004954340Medicare PIN
WI240007251Medicare PIN
WI067474150Medicare PIN
WI570850187Medicare PIN