Provider Demographics
NPI:1790550804
Name:KING, MARIETTA ESTELLE (NP)
Entity Type:Individual
Prefix:
First Name:MARIETTA
Middle Name:ESTELLE
Last Name:KING
Suffix:
Gender:F
Credentials:NP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:61844 POPULAR RD
Mailing Address - Street 2:
Mailing Address - City:MONTROSE
Mailing Address - State:CO
Mailing Address - Zip Code:81403-9664
Mailing Address - Country:US
Mailing Address - Phone:970-765-6760
Mailing Address - Fax:
Practice Address - Street 1:800 S 3RD ST
Practice Address - Street 2:
Practice Address - City:MONTROSE
Practice Address - State:CO
Practice Address - Zip Code:81401-4212
Practice Address - Country:US
Practice Address - Phone:970-765-6760
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2023-11-20
Last Update Date:2023-11-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
COAPN.0999306-NP207R00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207R00000XAllopathic & Osteopathic PhysiciansInternal Medicine