Provider Demographics
NPI:1437447414
Name:KING, JONATHAN JERSHAUN (MD)
Entity Type:Individual
Prefix:
First Name:JONATHAN
Middle Name:JERSHAUN
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 1:317 E GRAND RIVER RD
Mailing Address - Street 2:
Mailing Address - City:LAINGSBURG
Mailing Address - State:MI
Mailing Address - Zip Code:48848-8742
Mailing Address - Country:US
Mailing Address - Phone:517-651-2801
Mailing Address - Fax:517-651-2310
Practice Address - Street 1:317 E GRAND RIVER RD
Practice Address - Street 2:
Practice Address - City:LAINGSBURG
Practice Address - State:MI
Practice Address - Zip Code:48848-8742
Practice Address - Country:US
Practice Address - Phone:517-651-2801
Practice Address - Fax:517-651-2310
Is Sole Proprietor?:No
Enumeration Date:2011-07-12
Last Update Date:2017-04-04
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI4301098783207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
MI1437447414Medicaid
MIN53550118Medicare PIN