Provider Demographics
NPI:1972919116
Name:KINGS MEDICAL GROUP PC
Entity type:Organization
Organization Name:KINGS MEDICAL GROUP PC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:
Authorized Official - First Name:JOHN
Authorized Official - Middle Name:R
Authorized Official - Last Name:GAVINI
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:559-410-8404
Mailing Address - Street 1:240 N 12TH AVE
Mailing Address - Street 2:SUITE 109 #303
Mailing Address - City:HANFORD
Mailing Address - State:CA
Mailing Address - Zip Code:93230-5995
Mailing Address - Country:US
Mailing Address - Phone:559-410-8404
Mailing Address - Fax:
Practice Address - Street 1:808 VAUGHN ST
Practice Address - Street 2:
Practice Address - City:HANFORD
Practice Address - State:CA
Practice Address - Zip Code:93230
Practice Address - Country:US
Practice Address - Phone:559-410-8404
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2014-07-09
Last Update Date:2016-12-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAA77882207R00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207R00000XAllopathic & Osteopathic PhysiciansInternal MedicineGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
CA134898Medicare PIN