Provider Demographics
NPI:1851518831
Name:KING, TONY ROOSEVELT (MD)
Entity Type:Individual
Prefix:
First Name:TONY
Middle Name:ROOSEVELT
Last Name:KING
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:13428 QUEEN ST
Mailing Address - Street 2:
Mailing Address - City:DISPUTANTA
Mailing Address - State:VA
Mailing Address - Zip Code:23842-6235
Mailing Address - Country:US
Mailing Address - Phone:804-991-9101
Mailing Address - Fax:
Practice Address - Street 1:13428 QUEEN ST
Practice Address - Street 2:
Practice Address - City:DISPUTANTA
Practice Address - State:VA
Practice Address - Zip Code:23842-6235
Practice Address - Country:US
Practice Address - Phone:804-991-9101
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2007-04-19
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
VA48987207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
VA56-1868-1Medicaid
VA56-1868-1Medicaid