Provider Demographics
NPI:1669476396
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 1:4411 THE 25 WAY NE
Mailing Address - Street 2:STE 150
Mailing Address - City:ALBUQUERQUE
Mailing Address - State:NM
Mailing Address - Zip Code:87109-5888
Mailing Address - Country:US
Mailing Address - Phone:505-332-6900
Mailing Address - Fax:505-332-6921
Practice Address - Street 1:4411 THE 25 WAY NE
Practice Address - Street 2:STE 150
Practice Address - City:ALBUQUERQUE
Practice Address - State:NM
Practice Address - Zip Code:87109-5888
Practice Address - Country:US
Practice Address - Phone:505-332-6900
Practice Address - Fax:505-332-6921
Is Sole Proprietor?:No
Enumeration Date:2005-06-10
Last Update Date:2014-03-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NM80-522085R0204X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2085R0204XAllopathic & Osteopathic PhysiciansRadiologyVascular & Interventional Radiology
Provider Identifiers
StateIdentifier IDID TypeIssuer
NM45138Medicaid
NM52713Medicaid
NM700521102OtherMEDICARE GROUP
NML0634Medicaid
NM2258272OtherMEDICARE GROUP
NM600521002OtherMEDICARE IDTF
NM800521126OtherMEDICARE IDTF
NM9035Medicaid
NM$$$$$$$$$MMedicare PIN
NMD05794Medicare UPIN