Provider Demographics
NPI:1174550867
Name:KING, SAMUEL JEROME (M D)
Entity type:Individual
Prefix:
First Name:SAMUEL
Middle Name:JEROME
Last Name:KING
Suffix:
Gender:M
Credentials:M D
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:PO BOX 432
Mailing Address - Street 2:
Mailing Address - City:PIKEVILLE
Mailing Address - State:KY
Mailing Address - Zip Code:41502-0432
Mailing Address - Country:US
Mailing Address - Phone:606-430-2220
Mailing Address - Fax:606-432-6665
Practice Address - Street 1:911 BYPASS RD BLDG B
Practice Address - Street 2:
Practice Address - City:PIKEVILLE
Practice Address - State:KY
Practice Address - Zip Code:41501-1689
Practice Address - Country:US
Practice Address - Phone:606-430-2220
Practice Address - Fax:606-432-6665
Is Sole Proprietor?:No
Enumeration Date:2006-06-27
Last Update Date:2023-03-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
KY22790207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
KY64227903Medicaid
KY64227903Medicaid
KY64227903Medicaid
AK2198047OtherDEA