Provider Demographics
NPI:1255506671
Name:KING, JERRY N (MD)
Entity Type:Individual
Prefix:
First Name:JERRY
Middle Name:N
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 1:12731 S 83RD CT
Mailing Address - Street 2:
Mailing Address - City:PALOS PARK
Mailing Address - State:IL
Mailing Address - Zip Code:60464-2026
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:12731 S 83RD CT
Practice Address - Street 2:
Practice Address - City:PALOS PARK
Practice Address - State:IL
Practice Address - Zip Code:60464-2026
Practice Address - Country:US
Practice Address - Phone:708-361-0020
Practice Address - Fax:708-361-5392
Is Sole Proprietor?:Yes
Enumeration Date:2008-04-27
Last Update Date:2008-04-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL036-050984208600000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208600000XAllopathic & Osteopathic PhysiciansSurgery
Provider Identifiers
StateIdentifier IDID TypeIssuer
IL036-050984OtherILLINOIS STATE MEDICAL LICENSE