Provider Demographics
NPI:1780709279
Name:KING, PHILLIP LEE JR (OD)
Entity type:Individual
Prefix:DR
First Name:PHILLIP
Middle Name:LEE
Last Name:KING
Suffix:JR
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 1:3429 NORTH 5TH ST
Mailing Address - Street 2:
Mailing Address - City:OCEAN SPRINGS
Mailing Address - State:MS
Mailing Address - Zip Code:39564
Mailing Address - Country:US
Mailing Address - Phone:601-766-3800
Mailing Address - Fax:601-947-2709
Practice Address - Street 1:11228 HWY 63S
Practice Address - Street 2:
Practice Address - City:LUCEDALE
Practice Address - State:MS
Practice Address - Zip Code:39452
Practice Address - Country:US
Practice Address - Phone:601-766-3800
Practice Address - Fax:601-947-2709
Is Sole Proprietor?:No
Enumeration Date:2007-03-21
Last Update Date:2007-07-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MS683152W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes152W00000XEye and Vision Services ProvidersOptometrist
Provider Identifiers
StateIdentifier IDID TypeIssuer
V05658Medicare UPIN
C03344Medicare UPIN
C03344Medicare ID - Type UnspecifiedGROUP