Provider Demographics
NPI:1336203231
Name:KING, ERIC N (OD)
Entity Type:Individual
Prefix:
First Name:ERIC
Middle Name:N
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 1:101 US HIGHWAY 150 BYP
Mailing Address - Street 2:SUITE 117
Mailing Address - City:STANFORD
Mailing Address - State:KY
Mailing Address - Zip Code:40484-1034
Mailing Address - Country:US
Mailing Address - Phone:606-365-2195
Mailing Address - Fax:606-365-2195
Practice Address - Street 1:101 US HIGHWAY 150 BYP
Practice Address - Street 2:SUITE 117
Practice Address - City:STANFORD
Practice Address - State:KY
Practice Address - Zip Code:40484-1034
Practice Address - Country:US
Practice Address - Phone:606-365-2195
Practice Address - Fax:606-365-2195
Is Sole Proprietor?:Yes
Enumeration Date:2006-12-22
Last Update Date:2014-11-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
KYKY1294DT152W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes152W00000XEye and Vision Services ProvidersOptometrist
Provider Identifiers
StateIdentifier IDID TypeIssuer
KY5281470001OtherPALMETTO PROVIDER ID
KY77012946Medicaid
KY5281470001OtherPALMETTO PROVIDER ID
KY77012946Medicaid