Provider Demographics
NPI:1720071517
Name:KING, DAVID R (OD)
Entity Type:Individual
Prefix:
First Name:DAVID
Middle Name:R
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 1:2020 HIGH ST
Mailing Address - Street 2:SUITE I
Mailing Address - City:SELMA
Mailing Address - State:CA
Mailing Address - Zip Code:93662-3518
Mailing Address - Country:US
Mailing Address - Phone:559-896-3937
Mailing Address - Fax:559-896-3090
Practice Address - Street 1:2020 HIGH ST
Practice Address - Street 2:SUITE I
Practice Address - City:SELMA
Practice Address - State:CA
Practice Address - Zip Code:93662-3518
Practice Address - Country:US
Practice Address - Phone:559-896-3937
Practice Address - Fax:559-896-3090
Is Sole Proprietor?:Yes
Enumeration Date:2005-08-26
Last Update Date:2012-06-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA10350TPL152W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes152W00000XEye and Vision Services ProvidersOptometrist
Provider Identifiers
StateIdentifier IDID TypeIssuer
CASD0103500Medicaid
CASD0103500Medicare ID - Type Unspecified
CASD0103500Medicaid