Provider Demographics
NPI:1346205689
Name:KING, JERRY D (OD)
Entity Type:Individual
Prefix:DR
First Name:JERRY
Middle Name:D
Last Name:KING
Suffix:
Gender:M
Credentials:OD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:115 N OAK ST
Mailing Address - Street 2:
Mailing Address - City:ELDON
Mailing Address - State:MO
Mailing Address - Zip Code:65026-1444
Mailing Address - Country:US
Mailing Address - Phone:573-392-7126
Mailing Address - Fax:573-392-0800
Practice Address - Street 1:115 N OAK ST
Practice Address - Street 2:
Practice Address - City:ELDON
Practice Address - State:MO
Practice Address - Zip Code:65026-1444
Practice Address - Country:US
Practice Address - Phone:573-392-7126
Practice Address - Fax:573-392-0800
Is Sole Proprietor?:Yes
Enumeration Date:2006-04-19
Last Update Date:2008-07-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MOTO2349152W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes152W00000XEye and Vision Services ProvidersOptometrist
Provider Identifiers
StateIdentifier IDID TypeIssuer
MO310039805Medicaid
MO310039805Medicaid
MO0492550001Medicare NSC
MO000006040Medicare PIN