Provider Demographics
NPI:1942829171
Name:KING, KALEB (MD)
Entity Type:Individual
Prefix:
First Name:KALEB
Middle Name:
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 1:1501 E 19TH ST
Mailing Address - Street 2:
Mailing Address - City:EDMOND
Mailing Address - State:OK
Mailing Address - Zip Code:73013-6618
Mailing Address - Country:US
Mailing Address - Phone:405-348-6611
Mailing Address - Fax:405-348-9280
Practice Address - Street 1:1501 E 19TH ST
Practice Address - Street 2:
Practice Address - City:EDMOND
Practice Address - State:OK
Practice Address - Zip Code:73013-6618
Practice Address - Country:US
Practice Address - Phone:405-348-6611
Practice Address - Fax:405-348-9280
Is Sole Proprietor?:No
Enumeration Date:2020-04-08
Last Update Date:2023-09-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OK41812207Q00000X
390200000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
No390200000XStudent, Health CareStudent in an Organized Health Care Education/Training Program