Provider Demographics
NPI:1417020462
Name:KING, JERRY LEE (OD)
Entity Type:Individual
Prefix:DR
First Name:JERRY
Middle Name:LEE
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 1:103 W LOOP 281
Mailing Address - Street 2:SUITE 450
Mailing Address - City:LONGVIEW
Mailing Address - State:TX
Mailing Address - Zip Code:75605-4653
Mailing Address - Country:US
Mailing Address - Phone:903-663-2020
Mailing Address - Fax:903-663-2353
Practice Address - Street 1:103 W LOOP 281
Practice Address - Street 2:STE 450
Practice Address - City:LONGVIEW
Practice Address - State:TX
Practice Address - Zip Code:75605-4653
Practice Address - Country:US
Practice Address - Phone:903-663-2020
Practice Address - Fax:903-663-2353
Is Sole Proprietor?:Yes
Enumeration Date:2006-11-16
Last Update Date:2008-07-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TX2926TG152W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes152W00000XEye and Vision Services ProvidersOptometrist
Provider Identifiers
StateIdentifier IDID TypeIssuer
TX093291502Medicaid
TX093291502Medicaid
T14197Medicare UPIN