Provider Demographics
NPI:1962492603
Name:KING, MARYETTA E (MD)
Entity Type:Individual
Prefix:DR
First Name:MARYETTA
Middle Name:E
Last Name:KING
Suffix:
Gender:F
Credentials:MD
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Mailing Address - Street 1:PO BOX 9142
Mailing Address - Street 2:
Mailing Address - City:CHARLESTOWN
Mailing Address - State:MA
Mailing Address - Zip Code:02129-9142
Mailing Address - Country:US
Mailing Address - Phone:617-724-0287
Mailing Address - Fax:617-726-2894
Practice Address - Street 1:55 FRUIT STREET
Practice Address - Street 2:YAWKEY 5-062 MASSACHUSETTS GENERAL HOSPITAL
Practice Address - City:BOSTON
Practice Address - State:MA
Practice Address - Zip Code:02114-2696
Practice Address - Country:US
Practice Address - Phone:617-726-3826
Practice Address - Fax:617-643-1639
Is Sole Proprietor?:No
Enumeration Date:2005-10-25
Last Update Date:2009-09-02
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Provider Licenses
StateLicense IDTaxonomies
MA38249208000000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208000000XAllopathic & Osteopathic PhysiciansPediatrics
Provider Identifiers
StateIdentifier IDID TypeIssuer
MA724773OtherTUFTS HEALTH PLAN
MAB11517OtherBCBS MA
MA6171613Medicaid
E02975Medicare UPIN
MA724773OtherTUFTS HEALTH PLAN