Provider Demographics
NPI:1760517270
Name:KING, WILLETTE (OD)
Entity Type:Individual
Prefix:DR
First Name:WILLETTE
Middle Name:
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 1:5 PINE ST
Mailing Address - Street 2:APT B
Mailing Address - City:BOSTON
Mailing Address - State:MA
Mailing Address - Zip Code:02111-1424
Mailing Address - Country:US
Mailing Address - Phone:617-306-1703
Mailing Address - Fax:
Practice Address - Street 1:196A MAIN ST
Practice Address - Street 2:
Practice Address - City:STONEHAM
Practice Address - State:MA
Practice Address - Zip Code:02180-1619
Practice Address - Country:US
Practice Address - Phone:781-438-0290
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2007-02-23
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MA4610152W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes152W00000XEye and Vision Services ProvidersOptometrist