Provider Demographics
NPI:1750469680
Name:KING, KENNETH BRIAN (OD)
Entity Type:Individual
Prefix:DR
First Name:KENNETH
Middle Name:BRIAN
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 1:9429 N BEACH ST
Mailing Address - Street 2:
Mailing Address - City:FORT WORTH
Mailing Address - State:TX
Mailing Address - Zip Code:76244-9059
Mailing Address - Country:US
Mailing Address - Phone:817-442-2020
Mailing Address - Fax:682-499-3856
Practice Address - Street 1:9429 N BEACH ST
Practice Address - Street 2:
Practice Address - City:FORT WORTH
Practice Address - State:TX
Practice Address - Zip Code:76244-9059
Practice Address - Country:US
Practice Address - Phone:817-442-2020
Practice Address - Fax:682-499-3856
Is Sole Proprietor?:Yes
Enumeration Date:2006-11-01
Last Update Date:2023-12-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TX04669T152W00000X, 152W00000X
CAOPT 12053152W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes152W00000XEye and Vision Services ProvidersOptometrist
Provider Identifiers
StateIdentifier IDID TypeIssuer
OH0959922Medicaid
OHK0757341Medicare ID - Type Unspecified
OH0959922Medicaid