Healthcare Provider Details

I. General information

NPI: 1669459327
Provider Name (Legal Business Name): SUSAN C KING MD
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 12/23/2005
Last Update Date: 07/22/2011
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1907 CYPRESS CREEK RD SUITE 104
CEDAR PARK TX
78613-4150
US

IV. Provider business mailing address

1907 CYPRESS CREEK RD SUITE 104
CEDAR PARK TX
78613-4150
US

V. Phone/Fax

Practice location:
  • Phone: 512-346-7966
  • Fax: 512-346-7196
Mailing address:
  • Phone: 512-346-7966
  • Fax: 512-346-7196

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207Q00000X
TaxonomyFamily Medicine Physician
License NumberL1633
License Number StateTX

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: