Provider Demographics
NPI:1891796074
Name:KING, LORI MASSEY (MD)
Entity Type:Individual
Prefix:
First Name:LORI
Middle Name:MASSEY
Last Name:KING
Suffix:
Gender:F
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:200 PECAN CRK
Mailing Address - Street 2:
Mailing Address - City:SOUTHLAKE
Mailing Address - State:TX
Mailing Address - Zip Code:76092-6372
Mailing Address - Country:US
Mailing Address - Phone:817-481-4739
Mailing Address - Fax:817-481-5198
Practice Address - Street 1:200 PECAN CRK
Practice Address - Street 2:
Practice Address - City:SOUTHLAKE
Practice Address - State:TX
Practice Address - Zip Code:76092-6372
Practice Address - Country:US
Practice Address - Phone:817-481-4739
Practice Address - Fax:817-481-5198
Is Sole Proprietor?:Yes
Enumeration Date:2005-08-10
Last Update Date:2010-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TXJ4267207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
TX88761SOtherBCBS
TX87621NMedicare ID - Type Unspecified
TX88761SOtherBCBS