Provider Demographics
NPI:1639239692
Name:KING, CLINTON ALLEN (MD)
Entity Type:Individual
Prefix:DR
First Name:CLINTON
Middle Name:ALLEN
Last Name:KING
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
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Other - Credentials:
Mailing Address - Street 1:10657 VISTA DEL SOL
Mailing Address - Street 2:SUITE A
Mailing Address - City:EL PASO
Mailing Address - State:TX
Mailing Address - Zip Code:79935-4504
Mailing Address - Country:US
Mailing Address - Phone:915-598-3943
Mailing Address - Fax:915-598-3557
Practice Address - Street 1:10657 VISTA DEL SOL
Practice Address - Street 2:SUITE A
Practice Address - City:EL PASO
Practice Address - State:TX
Practice Address - Zip Code:79935-4504
Practice Address - Country:US
Practice Address - Phone:915-598-3943
Practice Address - Fax:915-598-3557
Is Sole Proprietor?:No
Enumeration Date:2006-12-11
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TXE2655207N00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207N00000XAllopathic & Osteopathic PhysiciansDermatology
Provider Identifiers
StateIdentifier IDID TypeIssuer
C17901Medicare UPIN
00AB40Medicare ID - Type Unspecified