Provider Demographics
NPI:1750518023
Name:KING, GLEN R (MD)
Entity type:Individual
Prefix:
First Name:GLEN
Middle Name:R
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:PO BOX 2016
Mailing Address - Street 2:
Mailing Address - City:CARTERSVILLE
Mailing Address - State:GA
Mailing Address - Zip Code:30120-1684
Mailing Address - Country:US
Mailing Address - Phone:770-382-0185
Mailing Address - Fax:770-382-0247
Practice Address - Street 1:40 FOX CHASE
Practice Address - Street 2:
Practice Address - City:CARTERSVILLE
Practice Address - State:GA
Practice Address - Zip Code:30120-2491
Practice Address - Country:US
Practice Address - Phone:770-382-0185
Practice Address - Fax:770-382-0247
Is Sole Proprietor?:No
Enumeration Date:2009-06-15
Last Update Date:2012-12-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GA33127207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine