Basic Information
| Provider Information | |||||||||
| NPI: | 1013058536 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | KING | ||||||||
| FirstName: | JOSEPH | ||||||||
| MiddleName: | D. | ||||||||
| NamePrefix: | MR. | ||||||||
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| Credential: | MD | ||||||||
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| Mailing Information | |||||||||
| Address1: | 2500 N STATE ST | ||||||||
| Address2: | |||||||||
| City: | JACKSON | ||||||||
| State: | MS | ||||||||
| PostalCode: | 392164500 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 6018151196 | ||||||||
| FaxNumber: | 6019845939 | ||||||||
| Practice Location | |||||||||
| Address1: | 4821 MERLOT AVENUE | ||||||||
| Address2: | SUITE 210 | ||||||||
| City: | GRAPEVINE | ||||||||
| State: | TX | ||||||||
| PostalCode: | 76051 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 9728673627 | ||||||||
| FaxNumber: | 8174217560 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 02/08/2007 | ||||||||
| LastUpdateDate: | 07/25/2018 | ||||||||
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| ProviderGenderCode: | M | ||||||||
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| IsSoleProprietor: | N | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 207LP3000X | 25782 | MS | Y | Allopathic & Osteopathic Physicians | Anesthesiology | Pediatric Anesthesiology | 207LP3000X | L6985 | TX | N | Allopathic & Osteopathic Physicians | Anesthesiology | Pediatric Anesthesiology |
ID Information
| ID | Type | State | Issuer | Description | 160325001 | 05 | TX | MEDICAID |