Provider Demographics
NPI:1124050497
Name:KING, MARY ELLEN (DO)
Entity type:Individual
Prefix:
First Name:MARY
Middle Name:ELLEN
Last Name:KING
Suffix:
Gender:F
Credentials:DO
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:155 CRYSTAL RUN RD
Mailing Address - Street 2:
Mailing Address - City:MIDDLETOWN
Mailing Address - State:NY
Mailing Address - Zip Code:10941-4028
Mailing Address - Country:US
Mailing Address - Phone:845-703-6999
Mailing Address - Fax:845-703-6297
Practice Address - Street 1:155 CRYSTAL RUN RD
Practice Address - Street 2:
Practice Address - City:MIDDLETOWN
Practice Address - State:NY
Practice Address - Zip Code:10941-4028
Practice Address - Country:US
Practice Address - Phone:845-703-6999
Practice Address - Fax:845-703-6297
Is Sole Proprietor?:No
Enumeration Date:2006-07-07
Last Update Date:2024-02-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY220224207RG0300X, 207R00000X, 208M00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207R00000XAllopathic & Osteopathic PhysiciansInternal Medicine
No207RG0300XAllopathic & Osteopathic PhysiciansInternal MedicineGeriatric Medicine
No208M00000XAllopathic & Osteopathic PhysiciansHospitalist
Provider Identifiers
StateIdentifier IDID TypeIssuer
NYMK0027SX20OtherBCBS
NY02192372Medicaid
H52251Medicare UPIN
MK028S1010Medicare PIN
NYMK0027SX20OtherBCBS
NY02192372Medicaid