Provider Demographics
NPI:1861408932
Name:KING, KELLY E (MD)
Entity type:Individual
Prefix:
First Name:KELLY
Middle Name:E
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 494
Mailing Address - Street 2:
Mailing Address - City:NASSAU
Mailing Address - State:DE
Mailing Address - Zip Code:19969-0494
Mailing Address - Country:US
Mailing Address - Phone:302-569-0352
Mailing Address - Fax:302-645-9714
Practice Address - Street 1:3600 JOSEPH SIEWICK DR
Practice Address - Street 2:
Practice Address - City:FAIRFAX
Practice Address - State:VA
Practice Address - Zip Code:22033
Practice Address - Country:US
Practice Address - Phone:703-391-3600
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2006-07-31
Last Update Date:2020-07-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
VA0101054870207PE0004X, 207P00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207P00000XAllopathic & Osteopathic PhysiciansEmergency Medicine
No207PE0004XAllopathic & Osteopathic PhysiciansEmergency MedicineEmergency Medical Services
Provider Identifiers
StateIdentifier IDID TypeIssuer
VA010113261Medicaid
VA010113261Medicaid
F69131Medicare UPIN