MEDICARE: LISA KING M.D.

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	207Q00000X	Family Medicine Physician	45295	KY

Other Identifiers

#	Provider Identifier	Provider Identifier Type	Provider Identifier State	Provider Identifier Issuer
1	MEDICAID ID Found: Get Medicaid Details using Online Medicaid Verification Program
2	MEDICAID ID Found: Get Medicaid Details using Online Medicaid Verification Program

General Provider Information

NPI Number	:	1164439451
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	LISA KING M.D.

Provider Business Mailing Address
First Line	:	6801 DIXIE HWY
Second Line	:	SUITE 130
City	:	LOUISVILLE
State	:	KY
Zip	:	40258-3913
Country	:	US
Telephone Number	:	502-968-6226
Fax Number	:	502-966-5562

Provider Business Practice Location Address
First Line	:	5100 OUTER LOOP
Second Line	:
City	:	LOUISVILLE
State	:	KY
Zip	:	40219-4056
Country	:	US
Telephone Number	:	502-968-6226
Fax Number	:	502-966-5562

Authorized Official
Title or Position	:
Name	:
Credential	:
Telephone Number	:

Provider Enumeration Date	:	08/01/2006
Last Update Date	:	07/29/2013

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