Provider Demographics
NPI:1548255367
Name:KING, GIDEON LEE (MD)
Entity type:Individual
Prefix:
First Name:GIDEON
Middle Name:LEE
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 1:6201 GENDER RD
Mailing Address - Street 2:
Mailing Address - City:CANAL WINCHESTER
Mailing Address - State:OH
Mailing Address - Zip Code:43110-2007
Mailing Address - Country:US
Mailing Address - Phone:614-834-8042
Mailing Address - Fax:614-837-8035
Practice Address - Street 1:6201 GENDER RD
Practice Address - Street 2:
Practice Address - City:CANAL WINCHESTER
Practice Address - State:OH
Practice Address - Zip Code:43110-2007
Practice Address - Country:US
Practice Address - Phone:614-834-8042
Practice Address - Fax:614-837-8035
Is Sole Proprietor?:Yes
Enumeration Date:2005-09-19
Last Update Date:2013-10-24
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OH35084584207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
OH2489561Medicaid
KI7375501Medicare PIN
OH2489561Medicaid