Provider Demographics
NPI:1487753380
Name:KING, CARROLL J (MD, JD)
Entity type:Individual
Prefix:
First Name:CARROLL
Middle Name:J
Last Name:KING
Suffix:
Gender:F
Credentials:MD, JD
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 7687
Mailing Address - Street 2:
Mailing Address - City:COLUMBIA
Mailing Address - State:MO
Mailing Address - Zip Code:65205-7687
Mailing Address - Country:US
Mailing Address - Phone:573-219-4270
Mailing Address - Fax:
Practice Address - Street 1:404 KEENE ST
Practice Address - Street 2:
Practice Address - City:COLUMBIA
Practice Address - State:MO
Practice Address - Zip Code:65201-6626
Practice Address - Country:US
Practice Address - Phone:573-219-4270
Practice Address - Fax:573-219-4279
Is Sole Proprietor?:No
Enumeration Date:2006-09-21
Last Update Date:2011-10-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TX40586208000000X
MO10332080P0203X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2080P0203XAllopathic & Osteopathic PhysiciansPediatricsPediatric Critical Care Medicine
No208000000XAllopathic & Osteopathic PhysiciansPediatrics
Provider Identifiers
StateIdentifier IDID TypeIssuer
TX169404401Medicaid
H08960Medicare UPIN
TX169404401Medicaid
MO152360540Medicare PIN