Provider Demographics
NPI:1548780133
Name:KING -GOVE, MOLLY JOAN (OD)
Entity Type:Individual
Prefix:DR
First Name:MOLLY
Middle Name:JOAN
Last Name:KING -GOVE
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 1:40 ROCKINGHAM AVE APT 204
Mailing Address - Street 2:
Mailing Address - City:WEST ROXBURY
Mailing Address - State:MA
Mailing Address - Zip Code:02132-4523
Mailing Address - Country:US
Mailing Address - Phone:908-268-6480
Mailing Address - Fax:
Practice Address - Street 1:468 HOSPITAL DR
Practice Address - Street 2:
Practice Address - City:ST JOHNSBURY
Practice Address - State:VT
Practice Address - Zip Code:05819-9225
Practice Address - Country:US
Practice Address - Phone:802-223-7723
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2017-06-23
Last Update Date:2020-12-04
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
VT030.0133932152W00000X
390200000X
MA5241152W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes152W00000XEye and Vision Services ProvidersOptometristGroup - Single Specialty
No390200000XStudent, Health CareStudent in an Organized Health Care Education/Training ProgramGroup - Single Specialty