Provider Demographics
NPI:1821101023
Name:JONATHAN S KING MD PC
Entity Type:Organization
Organization Name:JONATHAN S KING MD PC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PHYSICIAN
Authorized Official - Prefix:DR
Authorized Official - First Name:JONATHAN
Authorized Official - Middle Name:S
Authorized Official - Last Name:KING
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:208-667-7459
Mailing Address - Street 1:1107 W IRONWOOD DR
Mailing Address - Street 2:
Mailing Address - City:COEUR D ALENE
Mailing Address - State:ID
Mailing Address - Zip Code:83814-2604
Mailing Address - Country:US
Mailing Address - Phone:208-667-7459
Mailing Address - Fax:208-667-2631
Practice Address - Street 1:1107 W IRONWOOD DR
Practice Address - Street 2:
Practice Address - City:COEUR D ALENE
Practice Address - State:ID
Practice Address - Zip Code:83814-2604
Practice Address - Country:US
Practice Address - Phone:208-667-7459
Practice Address - Fax:208-667-2631
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-08-15
Last Update Date:2014-08-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IDM9264174400000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes174400000XOther Service ProvidersSpecialistGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
IDP00331085OtherRAILROAD MEDICARE
ID807235300Medicaid
ID5749450001Medicare NSC
IDI12839Medicare UPIN
ID1131434Medicare PIN