Provider Demographics
NPI:1861505448
Name:KING, JOHN J (MD)
Entity Type:Individual
Prefix:
First Name:JOHN
Middle Name:J
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 1:2323 5TH ST N
Mailing Address - Street 2:
Mailing Address - City:COLUMBUS
Mailing Address - State:MS
Mailing Address - Zip Code:39705-2213
Mailing Address - Country:US
Mailing Address - Phone:662-368-1169
Mailing Address - Fax:662-570-1492
Practice Address - Street 1:2323 5TH ST N
Practice Address - Street 2:
Practice Address - City:COLUMBUS
Practice Address - State:MS
Practice Address - Zip Code:39705-2213
Practice Address - Country:US
Practice Address - Phone:662-368-1169
Practice Address - Fax:662-570-1492
Is Sole Proprietor?:Yes
Enumeration Date:2006-08-16
Last Update Date:2019-06-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MS18685207RI0011X, 207R00000X, 207RI0011X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207RI0011XAllopathic & Osteopathic PhysiciansInternal MedicineInterventional Cardiology
No207R00000XAllopathic & Osteopathic PhysiciansInternal Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
MS04825058Medicaid
MS04825058Medicaid
MS110012016Medicare PIN