Provider Demographics
NPI:1639162597
Name:KING, WALTER LEE JR (OD)
Entity Type:Individual
Prefix:
First Name:WALTER
Middle Name:LEE
Last Name:KING
Suffix:JR
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 1:336 10TH AVE NE
Mailing Address - Street 2:
Mailing Address - City:HICKORY
Mailing Address - State:NC
Mailing Address - Zip Code:28601-3834
Mailing Address - Country:US
Mailing Address - Phone:828-322-4973
Mailing Address - Fax:828-322-1636
Practice Address - Street 1:336 10TH AVE NE
Practice Address - Street 2:
Practice Address - City:HICKORY
Practice Address - State:NC
Practice Address - Zip Code:28601-3834
Practice Address - Country:US
Practice Address - Phone:828-322-4973
Practice Address - Fax:828-322-1636
Is Sole Proprietor?:No
Enumeration Date:2005-08-25
Last Update Date:2013-06-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NC1831152W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes152W00000XEye and Vision Services ProvidersOptometrist
Provider Identifiers
StateIdentifier IDID TypeIssuer
NC89093GTMedicaid
NC2472012Medicare PIN
NC89093GTMedicaid