Provider Demographics
NPI:1558469106
Name:KING, KELLY (MD)
Entity Type:Individual
Prefix:DR
First Name:KELLY
Middle Name:
Last Name:KING
Suffix:
Gender:F
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:751 HORIZON CT
Mailing Address - Street 2:SUITE 202
Mailing Address - City:GRAND JUNCTION
Mailing Address - State:CO
Mailing Address - Zip Code:81506-8733
Mailing Address - Country:US
Mailing Address - Phone:970-242-4145
Mailing Address - Fax:970-242-4134
Practice Address - Street 1:751 HORIZON CT
Practice Address - Street 2:SUITE 202
Practice Address - City:GRAND JUNCTION
Practice Address - State:CO
Practice Address - Zip Code:81506-8733
Practice Address - Country:US
Practice Address - Phone:970-242-4145
Practice Address - Fax:970-242-4134
Is Sole Proprietor?:Yes
Enumeration Date:2006-09-20
Last Update Date:2012-10-31
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CO37446207R00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207R00000XAllopathic & Osteopathic PhysiciansInternal MedicineGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
CO020625894OtherFEDERAL TAX ID
CO477808Medicare ID - Type UnspecifiedMEDICARE INDIVIDUAL ID
CO020625894OtherFEDERAL TAX ID