Provider Demographics
NPI:1669465860
Name:KING, JOHN WESLEY JR (MD)
Entity Type:Individual
Prefix:
First Name:JOHN
Middle Name:WESLEY
Last Name:KING
Suffix:JR
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 1:250 MARTIN LUTHER KING JR BLVD
Mailing Address - Street 2:
Mailing Address - City:MACON
Mailing Address - State:GA
Mailing Address - Zip Code:31201-3490
Mailing Address - Country:US
Mailing Address - Phone:478-301-2362
Mailing Address - Fax:478-301-2272
Practice Address - Street 1:250 MARTIN LUTHER KING JR BLVD
Practice Address - Street 2:
Practice Address - City:MACON
Practice Address - State:GA
Practice Address - Zip Code:31201-3490
Practice Address - Country:US
Practice Address - Phone:478-301-4111
Practice Address - Fax:478-301-5812
Is Sole Proprietor?:No
Enumeration Date:2005-08-24
Last Update Date:2017-02-14
Deactivation Date:2006-03-27
Deactivation Code:
Reactivation Date:2006-06-26
Provider Licenses
StateLicense IDTaxonomies
GA021126207RP1001X, 207RC0200X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207RP1001XAllopathic & Osteopathic PhysiciansInternal MedicinePulmonary Disease
No207RC0200XAllopathic & Osteopathic PhysiciansInternal MedicineCritical Care Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
GA021126OtherGEORGIA LICENSE
GA00347608AMedicaid
GA52071710OtherBCBS GEORGIA
GA581714951OtherCHAMPVA COMMERCIAL
GA58171495131061OtherCHAMPUSTRICARETRICARLIFE
GA581714951OtherTIN
GA110020038Medicare PIN
GA58171495131061OtherCHAMPUSTRICARETRICARLIFE
D45853Medicare UPIN
GADU9791Medicare PIN