Provider Demographics
NPI:1558303784
Name:KING, GLEN W (DO)
Entity Type:Individual
Prefix:
First Name:GLEN
Middle Name:W
Last Name:KING
Suffix:
Gender:M
Credentials:DO
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
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Other - Last Name Type:
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Mailing Address - Street 1:6151 N MAIN STREET RD
Mailing Address - Street 2:
Mailing Address - City:WEBB CITY
Mailing Address - State:MO
Mailing Address - Zip Code:64870-8189
Mailing Address - Country:US
Mailing Address - Phone:417-781-0408
Mailing Address - Fax:417-556-5377
Practice Address - Street 1:6151 N MAIN STREET RD
Practice Address - Street 2:
Practice Address - City:WEBB CITY
Practice Address - State:MO
Practice Address - Zip Code:64870-8189
Practice Address - Country:US
Practice Address - Phone:417-781-0408
Practice Address - Fax:417-556-5377
Is Sole Proprietor?:No
Enumeration Date:2006-06-12
Last Update Date:2016-04-06
Deactivation Date:
Deactivation Code:
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Provider Licenses
StateLicense IDTaxonomies
MO113228207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
MOP00817803OtherRAIL ROAD MEDICARE
OK200090170AMedicaid
MO1558303784Medicaid
OK200090170AMedicaid
MOP00817803OtherRAIL ROAD MEDICARE
MO1558303784Medicaid