Provider Demographics
NPI:1437103066
Name:KING, KEVIN BARRY (OD)
Entity Type:Individual
Prefix:MR
First Name:KEVIN
Middle Name:BARRY
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 1:15330 MANOR VILLAGE LN
Mailing Address - Street 2:
Mailing Address - City:ROCKVILLE
Mailing Address - State:MD
Mailing Address - Zip Code:20853-1833
Mailing Address - Country:US
Mailing Address - Phone:301-929-3217
Mailing Address - Fax:
Practice Address - Street 1:8957 EDMONSTON RD
Practice Address - Street 2:SUITE E & G
Practice Address - City:GREENBELT
Practice Address - State:MD
Practice Address - Zip Code:20770-1005
Practice Address - Country:US
Practice Address - Phone:301-474-7712
Practice Address - Fax:301-220-0080
Is Sole Proprietor?:No
Enumeration Date:2006-05-19
Last Update Date:2011-08-25
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MDTA0955152W00000X
VA0618000593152W00000X
DC0P565152W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes152W00000XEye and Vision Services ProvidersOptometrist
Provider Identifiers
StateIdentifier IDID TypeIssuer
MDU38710Medicare UPIN
469446ZBUBMedicare PIN
P00869468Medicare PIN