Healthcare Provider Details

I. General information

NPI: 1780107987
Provider Name (Legal Business Name): CALEB RYAN KING MD
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 07/19/2017
Last Update Date: 08/29/2023
Certification Date: 08/29/2023
Deactivation Date:
Reactivation Date:

III. Provider practice location address

210 RINEHART RD
LAKE MARY FL
32746-2514
US

IV. Provider business mailing address

210 RINEHART RD
LAKE MARY FL
32746-2514
US

V. Phone/Fax

Practice location:
  • Phone: 321-843-2100
  • Fax: 321-842-3498
Mailing address:
  • Phone: 321-843-2100
  • Fax: 321-842-3498

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code390200000X
TaxonomyStudent in an Organized Health Care Education/Training Program
License NumberTRN25561
License Number StateFL
# 2
Primary TaxonomyN
Taxonomy Code2086X0206X
TaxonomySurgical Oncology Physician
License NumberMD477897
License Number StatePA
# 3
Primary TaxonomyY
Taxonomy Code2086X0206X
TaxonomySurgical Oncology Physician
License NumberME164092
License Number StateFL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: