=====================================================
General NPI Number Information
=====================================================
NPI Number | 1770858573
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | JUSTIN B KING MD INC
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 03/13/2012
-----------------------------------------------------
Last Update Date | 02/29/2024
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 6699 ALVARADO RD STE 2309
-----------------------------------------------------
City | SAN DIEGO
-----------------------------------------------------
State | CA
-----------------------------------------------------
Zip | 92120-5241
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 619-286-8803
-----------------------------------------------------
Fax | 619-286-2344
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | PO BOX 880768
-----------------------------------------------------
City | SAN DIEGO
-----------------------------------------------------
State | CA
-----------------------------------------------------
Zip | 92168-0768
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 310-792-3914
-----------------------------------------------------
Fax | 855-898-4055
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | PRESIDENT
-----------------------------------------------------
Name | DR. JUSTIN BENARD KING
-----------------------------------------------------
Credential | MD
-----------------------------------------------------
Telephone | 310-462-8668
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 208600000X
-----------------------------------------------------
Taxonomy Name | Surgery Physician
-----------------------------------------------------
License Number | A89447
-----------------------------------------------------
License Number State | CA
-----------------------------------------------------