Provider Demographics
NPI:1154465482
Name:KING, JERRY EVERETT (MD)
Entity Type:Individual
Prefix:
First Name:JERRY
Middle Name:EVERETT
Last Name:KING
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:10230 E ARROWVALE DR
Mailing Address - Street 2:
Mailing Address - City:SUN LAKES
Mailing Address - State:AZ
Mailing Address - Zip Code:85248-7649
Mailing Address - Country:US
Mailing Address - Phone:480-802-1259
Mailing Address - Fax:
Practice Address - Street 1:10180 SE SUNNYSIDE RD
Practice Address - Street 2:
Practice Address - City:CLACKAMAS
Practice Address - State:OR
Practice Address - Zip Code:97015-8970
Practice Address - Country:US
Practice Address - Phone:503-652-2880
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2007-02-19
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
ORMD089962085R0202X
WAMD000346392085R0202X
AZ309522085R0202X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2085R0202XAllopathic & Osteopathic PhysiciansRadiologyDiagnostic Radiology