Provider Demographics
NPI:1811938830
Name:KING, JONATHAN D (MD)
Entity type:Individual
Prefix:
First Name:JONATHAN
Middle Name:D
Last Name:KING
Suffix:
Gender:M
Credentials:MD
Other - Prefix:DR
Other - First Name:JONATHAN
Other - Middle Name:D
Other - Last Name:KING
Other - Suffix:
Other - Last Name Type:Professional Name
Other - Credentials:MD
Mailing Address - Street 1:157 CORLEY MILL ROAD
Mailing Address - Street 2:
Mailing Address - City:LEXINGTON
Mailing Address - State:SC
Mailing Address - Zip Code:29072
Mailing Address - Country:US
Mailing Address - Phone:803-256-2483
Mailing Address - Fax:803-799-4624
Practice Address - Street 1:157 CORLEY MILL RD
Practice Address - Street 2:STE 510
Practice Address - City:LEXINGTON
Practice Address - State:SC
Practice Address - Zip Code:29072-7600
Practice Address - Country:US
Practice Address - Phone:803-256-2483
Practice Address - Fax:803-799-4624
Is Sole Proprietor?:No
Enumeration Date:2006-06-09
Last Update Date:2014-11-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
SC19193207Y00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Y00000XAllopathic & Osteopathic PhysiciansOtolaryngology
Provider Identifiers
StateIdentifier IDID TypeIssuer
621111OtherSELECT HEALTH
C14633OtherRAILROAD MEDICARE GRP NUMBER
PA1382OtherMEDICAID GROUP NUMBER
040011784OtherRAILROAD MEDICARE
SC191937Medicaid
PA1382OtherMEDICAID GROUP NUMBER
G48924Medicare UPIN