Provider Demographics
NPI:1083663488
Name:KING, BRETT JOSEPH (OD)
Entity Type:Individual
Prefix:
First Name:BRETT
Middle Name:JOSEPH
Last Name:KING
Suffix:
Gender:M
Credentials:OD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:744 E 3RD ST
Mailing Address - Street 2:
Mailing Address - City:BLOOMINGTON
Mailing Address - State:IN
Mailing Address - Zip Code:47405-3603
Mailing Address - Country:US
Mailing Address - Phone:812-855-1344
Mailing Address - Fax:812-855-1683
Practice Address - Street 1:744 E 3RD ST
Practice Address - Street 2:
Practice Address - City:BLOOMINGTON
Practice Address - State:IN
Practice Address - Zip Code:47405-3603
Practice Address - Country:US
Practice Address - Phone:812-855-1344
Practice Address - Fax:812-855-1683
Is Sole Proprietor?:No
Enumeration Date:2006-05-10
Last Update Date:2015-10-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MOT03411152W00000X
KS1532-3152W00000X
IN18003817A152W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes152W00000XEye and Vision Services ProvidersOptometrist
Provider Identifiers
StateIdentifier IDID TypeIssuer
IN201192970Medicaid
IN544150008Medicare PIN
IN201192970Medicaid