Provider Demographics
NPI:1578598579
Name:KING, R KEITH (OD)
Entity Type:Individual
Prefix:
First Name:R
Middle Name:KEITH
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:PO BOX 469
Mailing Address - Street 2:
Mailing Address - City:RIPLEY
Mailing Address - State:WV
Mailing Address - Zip Code:25271
Mailing Address - Country:US
Mailing Address - Phone:304-372-8422
Mailing Address - Fax:304-372-4469
Practice Address - Street 1:RT 62 S
Practice Address - Street 2:
Practice Address - City:RIPLEY
Practice Address - State:WV
Practice Address - Zip Code:25271
Practice Address - Country:US
Practice Address - Phone:304-372-8422
Practice Address - Fax:304-372-4469
Is Sole Proprietor?:No
Enumeration Date:2006-07-11
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WV704D152W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes152W00000XEye and Vision Services ProvidersOptometrist
Provider Identifiers
StateIdentifier IDID TypeIssuer
219267OtherCARELINK
WV0150634000Medicaid
K19170611Medicare ID - Type Unspecified
219267OtherCARELINK