Provider Demographics
NPI:1720079148
Name:KING, MARK A (DO)
Entity type:Individual
Prefix:
First Name:MARK
Middle Name:A
Last Name:KING
Suffix:
Gender:M
Credentials:DO
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:250 N SHADELAND AVE
Mailing Address - Street 2:
Mailing Address - City:INDIANAPOLIS
Mailing Address - State:IN
Mailing Address - Zip Code:46219-4959
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:10101 ERNST RD STE 1100
Practice Address - Street 2:
Practice Address - City:ROANOKE
Practice Address - State:IN
Practice Address - Zip Code:46783-9711
Practice Address - Country:US
Practice Address - Phone:260-234-5400
Practice Address - Fax:260-234-5410
Is Sole Proprietor?:No
Enumeration Date:2005-11-03
Last Update Date:2025-01-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IN02001031A207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
000000091892OtherBLUE CROSS BLUE SHIELD
IN100318050Medicaid
E06645Medicare UPIN
INM400048054Medicare PIN
IN100318050Medicaid
INM400048054Medicare PIN
IN925500PMedicare PIN
IN925510CMedicare PIN
IN080121956OtherRAILROAD MEDICARE