Provider Demographics
NPI:1902888746
Name:KING, MARK D (MD)
Entity Type:Individual
Prefix:
First Name:MARK
Middle Name:D
Last Name:KING
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
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Mailing Address - Street 1:5450 WESTERN AVE
Mailing Address - Street 2:
Mailing Address - City:BOULDER
Mailing Address - State:CO
Mailing Address - Zip Code:80301-2709
Mailing Address - Country:US
Mailing Address - Phone:303-415-8850
Mailing Address - Fax:303-415-8870
Practice Address - Street 1:4800 RIVERBEND RD
Practice Address - Street 2:SUITE 200
Practice Address - City:BOULDER
Practice Address - State:CO
Practice Address - Zip Code:80301-2636
Practice Address - Country:US
Practice Address - Phone:303-415-8850
Practice Address - Fax:303-415-8870
Is Sole Proprietor?:No
Enumeration Date:2005-11-17
Last Update Date:2017-11-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CODR.0043187207RI0200X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207RI0200XAllopathic & Osteopathic PhysiciansInternal MedicineInfectious Disease
Provider Identifiers
StateIdentifier IDID TypeIssuer
CO73205338Medicaid
COC800820Medicare PIN
COG75177Medicare UPIN
COP00347674Medicare PIN