Provider Demographics
NPI:1164481123
Name:KING, GWENDOLYN J (OPTICIAN)
Entity Type:Individual
Prefix:
First Name:GWENDOLYN
Middle Name:J
Last Name:KING
Suffix:
Gender:F
Credentials:OPTICIAN
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:520 S PARROTT AVE
Mailing Address - Street 2:
Mailing Address - City:OKEECHOBEE
Mailing Address - State:FL
Mailing Address - Zip Code:34974-4345
Mailing Address - Country:US
Mailing Address - Phone:863-763-4334
Mailing Address - Fax:863-763-3226
Practice Address - Street 1:520 S PARROTT AVE
Practice Address - Street 2:
Practice Address - City:OKEECHOBEE
Practice Address - State:FL
Practice Address - Zip Code:34974-4345
Practice Address - Country:US
Practice Address - Phone:863-763-4334
Practice Address - Fax:863-763-3226
Is Sole Proprietor?:Not Answered
Enumeration Date:2006-03-20
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLDO2342156FX1800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes156FX1800XEye and Vision Services ProvidersTechnician/TechnologistOptician
Provider Identifiers
StateIdentifier IDID TypeIssuer
FL4774770001Medicare ID - Type Unspecified