Basic Information
Provider Information | |||||||||
NPI: | 1962508218 | ||||||||
EntityType: | 1 | ||||||||
ReplacementNPI: |   | ||||||||
OrganizationName: |   | ||||||||
LastName: | KING | ||||||||
FirstName: | JEFFREY | ||||||||
MiddleName: | C | ||||||||
NamePrefix: |   | ||||||||
NameSuffix: |   | ||||||||
Credential: | M.D. | ||||||||
OtherOrganizationName: |   | ||||||||
OtherOrganizationType: |   | ||||||||
OtherLastName: |   | ||||||||
OtherFirstName: |   | ||||||||
OtherMiddleName: |   | ||||||||
OtherNamePrefix: |   | ||||||||
OtherNameSuffix: |   | ||||||||
OtherCredential: |   | ||||||||
OtherLastNameType: |   | ||||||||
Mailing Information | |||||||||
Address1: | 3863 LEWISTON PL | ||||||||
Address2: |   | ||||||||
City: | FAIRFAX | ||||||||
State: | VA | ||||||||
PostalCode: | 220302423 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 5023779950 | ||||||||
FaxNumber: |   | ||||||||
Practice Location | |||||||||
Address1: | 9300 VALLEY CHILDRENS PL | ||||||||
Address2: |   | ||||||||
City: | MADERA | ||||||||
State: | CA | ||||||||
PostalCode: | 936368761 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 5593533000 | ||||||||
FaxNumber: |   | ||||||||
Other Information | |||||||||
ProviderEnumerationDate: | 09/15/2006 | ||||||||
LastUpdateDate: | 08/23/2019 | ||||||||
NPIDeactivationReasonCode: |   | ||||||||
NPIDeactivationDate: |   | ||||||||
NPIReactivationDate: |   | ||||||||
ProviderGenderCode: | M | ||||||||
AuthorizedOfficialLastName: |   | ||||||||
AuthorizedOfficialFirstName: |   | ||||||||
AuthorizedOfficialMiddleName: |   | ||||||||
AuthorizedOfficialTitleorPosition: |   | ||||||||
AuthorizedOfficialTelephone: |   | ||||||||
IsSoleProprietor: | Y | ||||||||
IsOrganizationSubpart: |   | ||||||||
ParentOrganizationLBN: |   | ||||||||
AuthorizedOfficialNamePrefix: |   | ||||||||
AuthorizedOfficialNameSuffix: |   | ||||||||
AuthorizedOfficialCredential: |   | ||||||||
NPICertificationDate: |   |
Taxonomy Information
Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 207VM0101X | G162824 | CA | N |   | Allopathic & Osteopathic Physicians | Obstetrics & Gynecology | Maternal & Fetal Medicine | 207VM0101X | 20100 | KY | N |   | Allopathic & Osteopathic Physicians | Obstetrics & Gynecology | Maternal & Fetal Medicine | 207VM0101X | 35068823 | OH | Y |   | Allopathic & Osteopathic Physicians | Obstetrics & Gynecology | Maternal & Fetal Medicine |
ID Information
ID | Type | State | Issuer | Description | 6493951500 | 05 | KY |   | MEDICAID | 000000571736 | 01 | KY | ANTHEM | OTHER | 200904930 | 05 | IN |   | MEDICAID | 50019626 | 01 | KY | PASSPORT PSC SPECIALITY | OTHER | 50020257 | 01 | KY | PASSPORT FOUNDATION SPECIALITY | OTHER | 0000000571093 | 01 | KY | ANTHEM | OTHER | 50020258 | 01 | KY | PASSPORT FOUNDATION PCP | OTHER |