Provider Demographics
NPI:1144256157
Name:KING, JAMES DARREL (MD)
Entity type:Individual
Prefix:
First Name:JAMES
Middle Name:DARREL
Last Name:KING
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1 PRIME CARE DR
Mailing Address - Street 2:
Mailing Address - City:SELMER
Mailing Address - State:TN
Mailing Address - Zip Code:38375-1864
Mailing Address - Country:US
Mailing Address - Phone:731-645-7932
Mailing Address - Fax:731-645-5195
Practice Address - Street 1:1 PRIME CARE DR
Practice Address - Street 2:
Practice Address - City:SELMER
Practice Address - State:TN
Practice Address - Zip Code:38375-1864
Practice Address - Country:US
Practice Address - Phone:731-645-7932
Practice Address - Fax:731-645-5195
Is Sole Proprietor?:No
Enumeration Date:2006-06-23
Last Update Date:2010-11-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TN14266207Q00000X
MS16404207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
TN116900Medicaid
TN12048Medicaid
TN3123017OtherBLUE CROSS BLUE SHIELD S
TN3717101Medicaid
TN3123019OtherBLUE CROSS BLUE SHIELD H
TN3124181OtherBLUE CROSS BLUE SHIELD A
TN116900Medicaid
TN3123019OtherBLUE CROSS BLUE SHIELD H
TN3842921Medicare ID - Type UnspecifiedADAMSVILLE
TN3842924Medicare ID - Type UnspecifiedSELMER
TN3717101Medicaid