Provider Demographics
NPI:1093733347
Name:KING, MATTHEW STEPHEN (OD)
Entity Type:Individual
Prefix:DR
First Name:MATTHEW
Middle Name:STEPHEN
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 1:1 CARDINAL RD
Mailing Address - Street 2:
Mailing Address - City:EAST LYME
Mailing Address - State:CT
Mailing Address - Zip Code:06333-1044
Mailing Address - Country:US
Mailing Address - Phone:860-739-7191
Mailing Address - Fax:
Practice Address - Street 1:761 BOSTON POST RD
Practice Address - Street 2:
Practice Address - City:OLD SAYBROOK
Practice Address - State:CT
Practice Address - Zip Code:06475-2126
Practice Address - Country:US
Practice Address - Phone:860-388-9300
Practice Address - Fax:860-395-2885
Is Sole Proprietor?:No
Enumeration Date:2006-07-17
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CTCT2644152W00000X
CAOPT 12593T152W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes152W00000XEye and Vision Services ProvidersOptometrist
Provider Identifiers
StateIdentifier IDID TypeIssuer
CT3539787OtherAETNA
CTP00099397OtherRAILROAD MEDICARE
CT090002644CT01OtherANTHEM
CT2V6356OtherHEALTHNET
CT020644OtherCONNECTICARE
CT090002644CT01OtherANTHEM