Provider Demographics
NPI:1174524722
Name:KING, KENNETH WILLIAM JR (OD)
Entity type:Individual
Prefix:DR
First Name:KENNETH
Middle Name:WILLIAM
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 1:1480 E LINCOLN RD
Mailing Address - Street 2:
Mailing Address - City:IDAHO FALLS
Mailing Address - State:ID
Mailing Address - Zip Code:83401-2128
Mailing Address - Country:US
Mailing Address - Phone:208-525-8686
Mailing Address - Fax:208-525-8684
Practice Address - Street 1:1480 E LINCOLN RD
Practice Address - Street 2:
Practice Address - City:IDAHO FALLS
Practice Address - State:ID
Practice Address - Zip Code:83401-2128
Practice Address - Country:US
Practice Address - Phone:208-525-8686
Practice Address - Fax:208-525-8684
Is Sole Proprietor?:Yes
Enumeration Date:2005-08-04
Last Update Date:2013-12-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IDODP0467152WC0802X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes152WC0802XEye and Vision Services ProvidersOptometristCorneal and Contact Management
Provider Identifiers
StateIdentifier IDID TypeIssuer
I-902428OtherCHAMPUS
0605250001OtherDMERC
ID82052OtherBLUE SHIELD
ID002543100Medicaid
0605250001OtherDMERC
ID002543100Medicaid
410006556Medicare ID - Type UnspecifiedRAILROAD MEDICARE