Healthcare Provider Details

I. General information

NPI: 1558303784
Provider Name (Legal Business Name): GLEN W. KING D.O.
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 06/12/2006
Last Update Date: 04/06/2016
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

6151 N MAIN STREET RD
WEBB CITY MO
64870-8189
US

IV. Provider business mailing address

6151 N MAIN STREET RD
WEBB CITY MO
64870-8189
US

V. Phone/Fax

Practice location:
  • Phone: 417-781-0408
  • Fax: 417-556-5377
Mailing address:
  • Phone: 417-781-0408
  • Fax: 417-556-5377

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207Q00000X
TaxonomyFamily Medicine Physician
License Number113228
License Number StateMO

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: