Provider Demographics
NPI:1164415014
Name:KING, WALTER LEE SR (MD)
Entity Type:Individual
Prefix:
First Name:WALTER
Middle Name:LEE
Last Name:KING
Suffix:SR
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:336 10TH AVE NE
Mailing Address - Street 2:
Mailing Address - City:HICKORY
Mailing Address - State:NC
Mailing Address - Zip Code:28601-3834
Mailing Address - Country:US
Mailing Address - Phone:828-322-4973
Mailing Address - Fax:828-322-1636
Practice Address - Street 1:336 10TH AVE NE
Practice Address - Street 2:
Practice Address - City:HICKORY
Practice Address - State:NC
Practice Address - Zip Code:28601-3834
Practice Address - Country:US
Practice Address - Phone:828-322-4973
Practice Address - Fax:828-322-1636
Is Sole Proprietor?:Yes
Enumeration Date:2005-08-25
Last Update Date:2013-06-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NC17219207W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207W00000XAllopathic & Osteopathic PhysiciansOphthalmology
Provider Identifiers
StateIdentifier IDID TypeIssuer
NC8949275Medicaid
C80613Medicare UPIN
NC0165810001Medicare NSC
NC201335Medicare PIN
2327691Medicare PIN