Provider Demographics
NPI:1891114666
Name:KING, JONATHAN RANDOLPH (DO)
Entity Type:Individual
Prefix:
First Name:JONATHAN
Middle Name:RANDOLPH
Last Name:KING
Suffix:
Gender:M
Credentials:DO
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:775 POLE LINE RD W
Mailing Address - Street 2:SUITE 312
Mailing Address - City:TWIN FALLS
Mailing Address - State:ID
Mailing Address - Zip Code:83301-5814
Mailing Address - Country:US
Mailing Address - Phone:208-814-8600
Mailing Address - Fax:208-814-8942
Practice Address - Street 1:775 POLE LINE RD W
Practice Address - Street 2:SUITE 312
Practice Address - City:TWIN FALLS
Practice Address - State:ID
Practice Address - Zip Code:83301-5814
Practice Address - Country:US
Practice Address - Phone:208-814-8600
Practice Address - Fax:208-814-8942
Is Sole Proprietor?:No
Enumeration Date:2014-04-09
Last Update Date:2023-10-25
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
UT13567339-1204207R00000X
IDO-1035207R00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207R00000XAllopathic & Osteopathic PhysiciansInternal Medicine