Provider Demographics
NPI:1558334003
Name:KING, NICOLE D (MD)
Entity Type:Individual
Prefix:
First Name:NICOLE
Middle Name:D
Last Name:KING
Suffix:
Gender:F
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
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Other - Credentials:
Mailing Address - Street 1:PO BOX 13677
Mailing Address - Street 2:
Mailing Address - City:BELFAST
Mailing Address - State:ME
Mailing Address - Zip Code:04915-4027
Mailing Address - Country:US
Mailing Address - Phone:773-667-0768
Mailing Address - Fax:773-667-5529
Practice Address - Street 1:9500 S DORCHESTER AVE
Practice Address - Street 2:SUITE 100
Practice Address - City:CHICAGO
Practice Address - State:IL
Practice Address - Zip Code:60628-1700
Practice Address - Country:US
Practice Address - Phone:773-667-0768
Practice Address - Fax:773-667-5529
Is Sole Proprietor?:Yes
Enumeration Date:2006-02-07
Last Update Date:2014-08-18
Deactivation Date:
Deactivation Code:
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Provider Licenses
StateLicense IDTaxonomies
IL036-096686207R00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207R00000XAllopathic & Osteopathic PhysiciansInternal Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
ILDD6694OtherRAILROAD MEDICARE
ILP00244611OtherRAILROAD MEDICARE
IL1634166OtherBC/BS
IL3474878OtherAETNA HMO
IL7779286OtherAETNA PPO
IL0061621OtherTRICARE
ILCIGNAOther7455146
IL1634166OtherBC/BS
ILP00244611OtherRAILROAD MEDICARE