Provider Demographics
NPI:1811216567
Name:KING, MELONIE DAWN (DO)
Entity Type:Individual
Prefix:DR
First Name:MELONIE
Middle Name:DAWN
Last Name:KING
Suffix:
Gender:F
Credentials:DO
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:379126 E 1140 RD
Mailing Address - Street 2:
Mailing Address - City:OKEMAH
Mailing Address - State:OK
Mailing Address - Zip Code:74859-1633
Mailing Address - Country:US
Mailing Address - Phone:918-851-6997
Mailing Address - Fax:
Practice Address - Street 1:1800 E COPLIN ST
Practice Address - Street 2:
Practice Address - City:OKEMAH
Practice Address - State:OK
Practice Address - Zip Code:74859-4642
Practice Address - Country:US
Practice Address - Phone:918-623-1424
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2010-05-20
Last Update Date:2023-01-04
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OK5074207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
OK5074OtherOK STATE LICENSE NUMBER
OK42551OtherOBNDD