Provider Demographics
NPI:1790776714
Name:KING, DEAN E (OD)
Entity Type:Individual
Prefix:
First Name:DEAN
Middle Name:E
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 1:900 E MORTON PL
Mailing Address - Street 2:
Mailing Address - City:HEMET
Mailing Address - State:CA
Mailing Address - Zip Code:92543-4529
Mailing Address - Country:US
Mailing Address - Phone:951-658-9409
Mailing Address - Fax:951-658-2057
Practice Address - Street 1:900 E MORTON PL
Practice Address - Street 2:
Practice Address - City:HEMET
Practice Address - State:CA
Practice Address - Zip Code:92543-4529
Practice Address - Country:US
Practice Address - Phone:951-658-9409
Practice Address - Fax:951-658-2057
Is Sole Proprietor?:Yes
Enumeration Date:2005-10-31
Last Update Date:2010-06-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAOPT5416T152W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes152W00000XEye and Vision Services ProvidersOptometrist
Provider Identifiers
StateIdentifier IDID TypeIssuer
CACA5416OtherEYEMED VISION ID#
CA48726OtherHEALTH NET VISION
CAOPT5416TOtherTRICARE/CHAMPUS
CA06639OtherMEDICAL EYE SERVICES ID #
CACA5416OtherEYEMED VISION ID#
TO9981Medicare UPIN