Provider Demographics
NPI:1982667804
Name:KING, ROBERT LEE (IDC)
Entity Type:Individual
Prefix:
First Name:ROBERT
Middle Name:LEE
Last Name:KING
Suffix:
Gender:M
Credentials:IDC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:12955 CANYON CREEK TRL S
Mailing Address - Street 2:
Mailing Address - City:JACKSONVILLE
Mailing Address - State:FL
Mailing Address - Zip Code:32246-6652
Mailing Address - Country:US
Mailing Address - Phone:904-992-9095
Mailing Address - Fax:
Practice Address - Street 1:NAVAL BRANCH HEALTH CLINIC
Practice Address - Street 2:2104 MASSEY AVENUE,
Practice Address - City:MAYPORT
Practice Address - State:FL
Practice Address - Zip Code:32228
Practice Address - Country:US
Practice Address - Phone:904-270-4241
Practice Address - Fax:
Is Sole Proprietor?:Not Answered
Enumeration Date:2006-04-11
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1710I1002XOther Service ProvidersMilitary Health Care ProviderIndependent Duty Corpsman