=====================================================
General NPI Number Information
=====================================================
NPI Number | 1396364808
-----------------------------------------------------
Entity Type | Individual
-----------------------------------------------------
Provider Name | RODERICK KING JR. MD
-----------------------------------------------------
Gender | Male
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 04/14/2020
-----------------------------------------------------
Last Update Date | 09/02/2025
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 116 CHRISTIE DR
-----------------------------------------------------
City | LUFKIN
-----------------------------------------------------
State | TX
-----------------------------------------------------
Zip | 75904-5534
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 302-345-3177
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 116 CHRISTIE DR
-----------------------------------------------------
City | LUFKIN
-----------------------------------------------------
State | TX
-----------------------------------------------------
Zip | 75904-5534
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 903-400-4744
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position |
-----------------------------------------------------
Name |
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone |
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 207L00000X
-----------------------------------------------------
Taxonomy Name | Anesthesiology Physician
-----------------------------------------------------
License Number | 69598
-----------------------------------------------------
License Number State | MN
-----------------------------------------------------
Taxonomy #2
-----------------------------------------------------
Taxonomy Code | 207R00000X
-----------------------------------------------------
Taxonomy Name | Internal Medicine Physician
-----------------------------------------------------
License Number | 30839
-----------------------------------------------------
License Number State | MN
-----------------------------------------------------
Taxonomy #3
-----------------------------------------------------
Taxonomy Code | 207LP2900X
-----------------------------------------------------
Taxonomy Name | Pain Medicine (Anesthesiology) Physician
-----------------------------------------------------
License Number | V8305
-----------------------------------------------------
License Number State | TX
-----------------------------------------------------