Basic Information
Provider Information | |||||||||
NPI: | 1144228966 | ||||||||
EntityType: | 1 | ||||||||
ReplacementNPI: |   | ||||||||
OrganizationName: |   | ||||||||
LastName: | KING | ||||||||
FirstName: | JEFFREY | ||||||||
MiddleName: | K. | ||||||||
NamePrefix: | DR. | ||||||||
NameSuffix: |   | ||||||||
Credential: | M.D. | ||||||||
OtherOrganizationName: |   | ||||||||
OtherOrganizationType: |   | ||||||||
OtherLastName: |   | ||||||||
OtherFirstName: |   | ||||||||
OtherMiddleName: |   | ||||||||
OtherNamePrefix: |   | ||||||||
OtherNameSuffix: |   | ||||||||
OtherCredential: |   | ||||||||
OtherLastNameType: |   | ||||||||
Mailing Information | |||||||||
Address1: | 7440 SOUTH 91ST STREET | ||||||||
Address2: |   | ||||||||
City: | LINCOLN | ||||||||
State: | NE | ||||||||
PostalCode: | 685269797 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 4024896555 | ||||||||
FaxNumber: | 4023283770 | ||||||||
Practice Location | |||||||||
Address1: | 3515 RICHMOND CIRCLE | ||||||||
Address2: |   | ||||||||
City: | GRAND ISLAND | ||||||||
State: | NE | ||||||||
PostalCode: | 688034965 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 3083818636 | ||||||||
FaxNumber: | 3083818622 | ||||||||
Other Information | |||||||||
ProviderEnumerationDate: | 07/14/2005 | ||||||||
LastUpdateDate: | 02/01/2012 | ||||||||
NPIDeactivationReasonCode: |   | ||||||||
NPIDeactivationDate: |   | ||||||||
NPIReactivationDate: |   | ||||||||
ProviderGenderCode: | M | ||||||||
AuthorizedOfficialLastName: |   | ||||||||
AuthorizedOfficialFirstName: |   | ||||||||
AuthorizedOfficialMiddleName: |   | ||||||||
AuthorizedOfficialTitleorPosition: |   | ||||||||
AuthorizedOfficialTelephone: |   | ||||||||
IsSoleProprietor: | N | ||||||||
IsOrganizationSubpart: |   | ||||||||
ParentOrganizationLBN: |   | ||||||||
AuthorizedOfficialNamePrefix: |   | ||||||||
AuthorizedOfficialNameSuffix: |   | ||||||||
AuthorizedOfficialCredential: |   | ||||||||
NPICertificationDate: |   |
Taxonomy Information
Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 207R00000X | 21858 | NE | N |   | Allopathic & Osteopathic Physicians | Internal Medicine |   | 207RC0000X | 21858 | NE | Y |   | Allopathic & Osteopathic Physicians | Internal Medicine | Cardiovascular Disease |
ID Information
ID | Type | State | Issuer | Description | 47070592300 | 05 | NE |   | MEDICAID | 47070592305 | 05 | NE |   | MEDICAID | 10026072500 | 05 | NE |   | MEDICAID | 200578840A | 05 | KS |   | MEDICAID | 47070592313 | 05 | NE |   | MEDICAID | 10026072400 | 05 | NE |   | MEDICAID | 10026072300 | 05 | NE |   | MEDICAID | 3202488 | 05 | IA |   | MEDICAID | 47070592301 | 05 | NE |   | MEDICAID | 47070592306 | 05 | NE |   | MEDICAID | 0202488 | 05 | IA |   | MEDICAID | 47070592302 | 05 | NE |   | MEDICAID |