Provider Demographics
NPI:1679505580
Name:KING, ELIZABETH L (MD)
Entity Type:Individual
Prefix:
First Name:ELIZABETH
Middle Name:L
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 1:2478 13TH ST SE
Mailing Address - Street 2:
Mailing Address - City:SALEM
Mailing Address - State:OR
Mailing Address - Zip Code:97302-2522
Mailing Address - Country:US
Mailing Address - Phone:503-362-2481
Mailing Address - Fax:503-371-7803
Practice Address - Street 1:2478 13TH ST SE
Practice Address - Street 2:
Practice Address - City:SALEM
Practice Address - State:OR
Practice Address - Zip Code:97302-2522
Practice Address - Country:US
Practice Address - Phone:503-362-2481
Practice Address - Fax:503-371-7803
Is Sole Proprietor?:No
Enumeration Date:2006-07-07
Last Update Date:2013-08-30
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLME91162208000000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208000000XAllopathic & Osteopathic PhysiciansPediatrics
Provider Identifiers
StateIdentifier IDID TypeIssuer
FL270725000Medicaid