Provider Demographics
NPI:1700857018
Name:KING, THOMAS MICHAEL (MD)
Entity Type:Individual
Prefix:
First Name:THOMAS
Middle Name:MICHAEL
Last Name:KING
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:THOMAS
Other - Middle Name:M
Other - Last Name:KING
Other - Suffix:
Other - Last Name Type:Other Name
Other - Credentials:
Mailing Address - Street 1:8100 34TH AVE S
Mailing Address - Street 2:MS 2111OQ
Mailing Address - City:BLOOMINGTON
Mailing Address - State:MN
Mailing Address - Zip Code:55425-1672
Mailing Address - Country:US
Mailing Address - Phone:952-431-8500
Mailing Address - Fax:952-431-6966
Practice Address - Street 1:15290 PENNOCK LN
Practice Address - Street 2:
Practice Address - City:APPLE VALLEY
Practice Address - State:MN
Practice Address - Zip Code:55124-7163
Practice Address - Country:US
Practice Address - Phone:952-431-8500
Practice Address - Fax:952-431-6966
Is Sole Proprietor?:No
Enumeration Date:2006-01-27
Last Update Date:2009-06-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MN29075207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
MN630582200Medicaid
MN630582200Medicaid
080006360Medicare ID - Type Unspecified