Provider Demographics
NPI:1558387290
Name:KING MEDICAL CORPORATION
Entity Type:Organization
Organization Name:KING MEDICAL CORPORATION
Other - Org Name:NOT ENOUGH SPACE
Other - Org Type:Other Name
Authorized Official - Title/Position:CORPORATION SECRETARY
Authorized Official - Prefix:DR
Authorized Official - First Name:CHARLES
Authorized Official - Middle Name:GERALD
Authorized Official - Last Name:WILLSON KING
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:818-728-4864
Mailing Address - Street 1:4910 VAN NUYS BLVD
Mailing Address - Street 2:SUITE 209
Mailing Address - City:SHERMAN OAKS
Mailing Address - State:CA
Mailing Address - Zip Code:91403-1715
Mailing Address - Country:US
Mailing Address - Phone:818-728-4864
Mailing Address - Fax:
Practice Address - Street 1:4910 VAN NUYS BLVD
Practice Address - Street 2:SUITE 209
Practice Address - City:SHERMAN OAKS
Practice Address - State:CA
Practice Address - Zip Code:91403-1715
Practice Address - Country:US
Practice Address - Phone:818-728-4864
Practice Address - Fax:818-728-4848
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-07-14
Last Update Date:2008-01-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAG9781207RA0201X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207RA0201XAllopathic & Osteopathic PhysiciansInternal MedicineAllergy & ImmunologyGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
CAC36227Medicare UPIN
CAC35313Medicare UPIN