Provider Demographics
NPI:1619063419
Name:KING, MARK (MD)
Entity Type:Individual
Prefix:DR
First Name:MARK
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 1:576 N SUNRISE AVE
Mailing Address - Street 2:SUITE 220
Mailing Address - City:ROSEVILLE
Mailing Address - State:CA
Mailing Address - Zip Code:95661-2841
Mailing Address - Country:US
Mailing Address - Phone:916-773-3444
Mailing Address - Fax:916-773-3474
Practice Address - Street 1:576 N SUNRISE AVE
Practice Address - Street 2:SUITE 220
Practice Address - City:ROSEVILLE
Practice Address - State:CA
Practice Address - Zip Code:95661-2841
Practice Address - Country:US
Practice Address - Phone:916-773-3444
Practice Address - Fax:916-773-3474
Is Sole Proprietor?:Yes
Enumeration Date:2006-10-05
Last Update Date:2013-11-04
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAA71357207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
CA00A713570Medicare ID - Type Unspecified
CAI44892Medicare UPIN