Provider Demographics
NPI:1861574725
Name:KING, GREGORY A (DPM)
Entity type:Individual
Prefix:
First Name:GREGORY
Middle Name:A
Last Name:KING
Suffix:
Gender:M
Credentials:DPM
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:35400 BOB HOPE DR STE 211
Mailing Address - Street 2:
Mailing Address - City:RANCHO MIRAGE
Mailing Address - State:CA
Mailing Address - Zip Code:92270-1774
Mailing Address - Country:US
Mailing Address - Phone:760-327-1254
Mailing Address - Fax:760-864-1499
Practice Address - Street 1:35400 BOB HOPE DR STE 211
Practice Address - Street 2:
Practice Address - City:RANCHO MIRAGE
Practice Address - State:CA
Practice Address - Zip Code:92270-1774
Practice Address - Country:US
Practice Address - Phone:760-327-1254
Practice Address - Fax:760-864-1499
Is Sole Proprietor?:Yes
Enumeration Date:2006-10-20
Last Update Date:2018-04-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAE3942213ES0131X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes213ES0131XPodiatric Medicine & Surgery Service ProvidersPodiatristFoot Surgery
Provider Identifiers
StateIdentifier IDID TypeIssuer
CACA238838Medicaid
CAU57900Medicare UPIN
CA4798320001Medicare NSC