Provider Demographics
NPI:1225131428
Name:KING, JAIME LYNNE (OD)
Entity Type:Individual
Prefix:DR
First Name:JAIME
Middle Name:LYNNE
Last Name:KING
Suffix:
Gender:F
Credentials:OD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
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Other - Credentials:
Mailing Address - Street 1:5915 E RIVERSIDE BLVD
Mailing Address - Street 2:
Mailing Address - City:ROCKFORD
Mailing Address - State:IL
Mailing Address - Zip Code:61114-4935
Mailing Address - Country:US
Mailing Address - Phone:815-316-2020
Mailing Address - Fax:815-316-0010
Practice Address - Street 1:695 N PERRYVILLE RD
Practice Address - Street 2:SUITE 3
Practice Address - City:ROCKFORD
Practice Address - State:IL
Practice Address - Zip Code:61107-6225
Practice Address - Country:US
Practice Address - Phone:815-316-2020
Practice Address - Fax:815-316-0010
Is Sole Proprietor?:Yes
Enumeration Date:2006-09-06
Last Update Date:2019-07-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL046009892152W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes152W00000XEye and Vision Services ProvidersOptometrist
Provider Identifiers
StateIdentifier IDID TypeIssuer
ILV10533Medicare UPIN
IL2751001Medicare UPIN