Provider Demographics
NPI:1629077649
Name:KING, COLLEEN M (OD)
Entity Type:Individual
Prefix:
First Name:COLLEEN
Middle Name:M
Last Name:KING
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 1:201 N HOGAN ST STE 100
Mailing Address - Street 2:
Mailing Address - City:JACKSONVILLE
Mailing Address - State:FL
Mailing Address - Zip Code:32202-4203
Mailing Address - Country:US
Mailing Address - Phone:904-356-9431
Mailing Address - Fax:904-356-2969
Practice Address - Street 1:201 N HOGAN ST STE 100
Practice Address - Street 2:
Practice Address - City:JACKSONVILLE
Practice Address - State:FL
Practice Address - Zip Code:32202-4203
Practice Address - Country:US
Practice Address - Phone:904-356-9431
Practice Address - Fax:904-356-2969
Is Sole Proprietor?:No
Enumeration Date:2005-07-20
Last Update Date:2022-05-31
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLOPC3718152W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes152W00000XEye and Vision Services ProvidersOptometrist
Provider Identifiers
StateIdentifier IDID TypeIssuer
0135179OtherGHI
FL620893200OtherMEDICAID INDIVIDUAL ID
FL45002OtherBCBS INDIVIDUAL
26115561OtherUNITED HEALTHCARE
FL7500506OtherAETNA
8700204OtherCIGNA
26115561OtherUNITED HEALTHCARE
FL45002OtherBCBS INDIVIDUAL
8700204OtherCIGNA