Provider Demographics
NPI:1811977325
Name:KING, JOHN (PHD)
Entity type:Individual
Prefix:
First Name:JOHN
Middle Name:
Last Name:KING
Suffix:
Gender:M
Credentials:PHD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:10110 SPAIN RD NE
Mailing Address - Street 2:
Mailing Address - City:ALBUQUERQUE
Mailing Address - State:NM
Mailing Address - Zip Code:87111-1965
Mailing Address - Country:US
Mailing Address - Phone:505-404-9395
Mailing Address - Fax:505-299-4740
Practice Address - Street 1:10110 SPAIN RD NE
Practice Address - Street 2:
Practice Address - City:ALBUQUERQUE
Practice Address - State:NM
Practice Address - Zip Code:87111-1965
Practice Address - Country:US
Practice Address - Phone:505-404-9395
Practice Address - Fax:505-299-4740
Is Sole Proprietor?:No
Enumeration Date:2006-01-19
Last Update Date:2021-05-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL71006364103G00000X
NM0969103G00000X
NMPSY-RXC0074103TP0016X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103TP0016XBehavioral Health & Social Service ProvidersPsychologistPrescribing (Medical)
No103G00000XBehavioral Health & Social Service ProvidersClinical Neuropsychologist
Provider Identifiers
StateIdentifier IDID TypeIssuer
IL71006364Medicaid
ILK07528Medicare ID - Type Unspecified
IL71006364Medicaid