Provider Demographics
NPI:1649249491
Name:KING, TERRY DEAN (MD)
Entity type:Individual
Prefix:
First Name:TERRY
Middle Name:DEAN
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 1:300 PAVILION RD
Mailing Address - Street 2:
Mailing Address - City:WEST MONROE
Mailing Address - State:LA
Mailing Address - Zip Code:71292-9470
Mailing Address - Country:US
Mailing Address - Phone:318-323-1100
Mailing Address - Fax:318-323-1161
Practice Address - Street 1:300 PAVILION RD
Practice Address - Street 2:
Practice Address - City:WEST MONROE
Practice Address - State:LA
Practice Address - Zip Code:71292-9470
Practice Address - Country:US
Practice Address - Phone:318-323-1100
Practice Address - Fax:318-323-1161
Is Sole Proprietor?:No
Enumeration Date:2006-03-15
Last Update Date:2015-10-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
LAMD.02443R2080P0202X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2080P0202XAllopathic & Osteopathic PhysiciansPediatricsPediatric Cardiology
Provider Identifiers
StateIdentifier IDID TypeIssuer
MS00017835Medicaid
LA1442399Medicaid
LA1109487Medicaid
MS00017835Medicaid
LA393236YH3VMedicare PIN
LA1109487Medicaid