Healthcare Provider Details

I. General information

NPI: 1073811931
Provider Name (Legal Business Name): DPMKINGPRNJ LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 03/02/2011
Last Update Date: 03/02/2011
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1195 HIGHWAY 70 SUITE 12
LAKEWOOD NJ
08701-5946
US

IV. Provider business mailing address

6 MOUNTAIN TRL
VERNON NJ
07462-3012
US

V. Phone/Fax

Practice location:
  • Phone: 732-905-7818
  • Fax:
Mailing address:
  • Phone: 216-401-7285
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code213E00000X
TaxonomyPodiatrist
License Number25MD00294000
License Number StatePA

VIII. Authorized Official

Name: JOHN KING
Title or Position: OWNER
Credential: DPM
Phone: 216-401-7285