Provider Demographics
NPI:1801144977
Name:KING, PHILLIP EUGENE (MD)
Entity type:Individual
Prefix:
First Name:PHILLIP
Middle Name:EUGENE
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 1:418 LAKESIDE DR
Mailing Address - Street 2:
Mailing Address - City:LIBERTY
Mailing Address - State:MO
Mailing Address - Zip Code:64068-3440
Mailing Address - Country:US
Mailing Address - Phone:816-792-3722
Mailing Address - Fax:816-792-3722
Practice Address - Street 1:418 LAKESIDE DR
Practice Address - Street 2:
Practice Address - City:LIBERTY
Practice Address - State:MO
Practice Address - Zip Code:64068-3440
Practice Address - Country:US
Practice Address - Phone:816-792-3722
Practice Address - Fax:816-792-3722
Is Sole Proprietor?:Yes
Enumeration Date:2012-08-21
Last Update Date:2012-08-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MO28051207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine