Provider Demographics
NPI:1790868453
Name:KING, PETER K (LCO, CO)
Entity Type:Individual
Prefix:
First Name:PETER
Middle Name:K
Last Name:KING
Suffix:
Gender:M
Credentials:LCO, CO
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:10455 NW 51ST ST
Mailing Address - Street 2:
Mailing Address - City:CORAL SPRINGS
Mailing Address - State:FL
Mailing Address - Zip Code:33076
Mailing Address - Country:US
Mailing Address - Phone:954-560-1029
Mailing Address - Fax:
Practice Address - Street 1:450 N STATE ROAD 7
Practice Address - Street 2:
Practice Address - City:PLANTATION
Practice Address - State:FL
Practice Address - Zip Code:33317-2834
Practice Address - Country:US
Practice Address - Phone:954-923-8883
Practice Address - Fax:954-925-2296
Is Sole Proprietor?:Yes
Enumeration Date:2006-10-23
Last Update Date:2016-12-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLORT 1211744P3200X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1744P3200XOther Service ProvidersSpecialistProsthetics Case Management
Provider Identifiers
StateIdentifier IDID TypeIssuer
FL1089010001Medicare NSC
FL025542400OtherMEDICAID NSC