Provider Demographics
NPI:1982912903
Name:KING, JEREMIAH LOIUS (IDC)
Entity Type:Individual
Prefix:MR
First Name:JEREMIAH
Middle Name:LOIUS
Last Name:KING
Suffix:
Gender:M
Credentials:IDC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:141 DEWEY AVE
Mailing Address - Street 2:
Mailing Address - City:GROTON
Mailing Address - State:CT
Mailing Address - Zip Code:06340-3337
Mailing Address - Country:US
Mailing Address - Phone:228-313-6708
Mailing Address - Fax:
Practice Address - Street 1:141 DEWEY AVE
Practice Address - Street 2:
Practice Address - City:GROTON
Practice Address - State:CT
Practice Address - Zip Code:06340-3337
Practice Address - Country:US
Practice Address - Phone:228-313-6708
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2010-09-24
Last Update Date:2010-09-24
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1710I1002XOther Service ProvidersMilitary Health Care ProviderIndependent Duty Corpsman