Provider Demographics
NPI:1205828589
Name:KING, DIANE A (OD)
Entity Type:Individual
Prefix:DR
First Name:DIANE
Middle Name:A
Last Name:KING
Suffix:
Gender:F
Credentials:OD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:137 QUEEN ANNE RD
Mailing Address - Street 2:
Mailing Address - City:BOGOTA
Mailing Address - State:NJ
Mailing Address - Zip Code:07603-1623
Mailing Address - Country:US
Mailing Address - Phone:201-488-7855
Mailing Address - Fax:201-488-1636
Practice Address - Street 1:137 QUEEN ANNE RD
Practice Address - Street 2:
Practice Address - City:BOGOTA
Practice Address - State:NJ
Practice Address - Zip Code:07603-1623
Practice Address - Country:US
Practice Address - Phone:201-488-7855
Practice Address - Fax:201-488-1636
Is Sole Proprietor?:Yes
Enumeration Date:2005-08-22
Last Update Date:2023-01-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NJ4478152W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes152W00000XEye and Vision Services ProvidersOptometrist
Provider Identifiers
StateIdentifier IDID TypeIssuer
NJ0226560001Medicare NSC
U26919Medicare UPIN
521592Medicare ID - Type Unspecified