Provider Demographics
NPI:1669465472
Name:KING, OLIVER W (MD)
Entity Type:Individual
Prefix:DR
First Name:OLIVER
Middle Name:W
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 1:1505 STONEBRIDGE PARKWAY
Mailing Address - Street 2:SUITE 100
Mailing Address - City:WOODSTOCK
Mailing Address - State:GA
Mailing Address - Zip Code:30189-8282
Mailing Address - Country:US
Mailing Address - Phone:770-423-0595
Mailing Address - Fax:770-874-1614
Practice Address - Street 1:61 WHITCHER STREET NE
Practice Address - Street 2:SUITE 2100
Practice Address - City:MARIETTA
Practice Address - State:GA
Practice Address - Zip Code:30060-1179
Practice Address - Country:US
Practice Address - Phone:770-423-0595
Practice Address - Fax:770-874-1614
Is Sole Proprietor?:No
Enumeration Date:2005-08-26
Last Update Date:2012-04-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GAD29931174400000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes174400000XOther Service ProvidersSpecialist
Provider Identifiers
StateIdentifier IDID TypeIssuer
AR00085775EMedicaid
AR00085775EMedicaid