Provider Demographics
NPI:1235390907
Name:KING, JEREMY DAVID (OD)
Entity type:Individual
Prefix:
First Name:JEREMY
Middle Name:DAVID
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 1:15951 LITTLE AXE DR
Mailing Address - Street 2:
Mailing Address - City:NORMAN
Mailing Address - State:OK
Mailing Address - Zip Code:73026-9088
Mailing Address - Country:US
Mailing Address - Phone:405-701-7900
Mailing Address - Fax:405-701-7914
Practice Address - Street 1:15702 EAST HIGHWAY 9
Practice Address - Street 2:
Practice Address - City:NORMAN
Practice Address - State:OK
Practice Address - Zip Code:73026
Practice Address - Country:US
Practice Address - Phone:405-447-0300
Practice Address - Fax:405-701-7914
Is Sole Proprietor?:No
Enumeration Date:2008-06-24
Last Update Date:2016-12-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OKOK2535152W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes152W00000XEye and Vision Services ProvidersOptometrist
Provider Identifiers
StateIdentifier IDID TypeIssuer
OK200222240AMedicaid
OK200222240AMedicaid
OKOK401506Medicare PIN