Provider Demographics
NPI:1144398405
Name:KINGSLEY, WILLIAM ROBERT
Entity Type:Individual
Prefix:MR
First Name:WILLIAM
Middle Name:ROBERT
Last Name:KINGSLEY
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1372 MARINA BAY DR
Mailing Address - Street 2:
Mailing Address - City:WATERTOWN
Mailing Address - State:SD
Mailing Address - Zip Code:57201-5487
Mailing Address - Country:US
Mailing Address - Phone:605-882-2180
Mailing Address - Fax:605-882-2180
Practice Address - Street 1:1300 9TH AVE SE
Practice Address - Street 2:
Practice Address - City:WATERTOWN
Practice Address - State:SD
Practice Address - Zip Code:57201-5387
Practice Address - Country:US
Practice Address - Phone:605-886-2038
Practice Address - Fax:605-886-2038
Is Sole Proprietor?:No
Enumeration Date:2006-12-02
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes156FX1800XEye and Vision Services ProvidersTechnician/TechnologistOptician
Provider Identifiers
StateIdentifier IDID TypeIssuer
SD9287310Medicaid
SD9287310Medicaid