Provider Demographics
NPI:1275932766
Name:KING, KEITH
Entity Type:Individual
Prefix:
First Name:KEITH
Middle Name:
Last Name:KING
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:81 VERONICA AVE STE 205
Mailing Address - Street 2:
Mailing Address - City:SOMERSET
Mailing Address - State:NJ
Mailing Address - Zip Code:08873-3491
Mailing Address - Country:US
Mailing Address - Phone:732-640-5316
Mailing Address - Fax:800-689-2361
Practice Address - Street 1:81 VERONICA AVE STE 205
Practice Address - Street 2:
Practice Address - City:SOMERSET
Practice Address - State:NJ
Practice Address - Zip Code:08873-3491
Practice Address - Country:US
Practice Address - Phone:732-640-5316
Practice Address - Fax:800-689-2361
Is Sole Proprietor?:No
Enumeration Date:2014-08-20
Last Update Date:2021-06-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
PAMD467059208600000X
NJ25MA10211600208600000X
NJK44864297106862208600000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208600000XAllopathic & Osteopathic PhysiciansSurgery