Healthcare Provider Details

I. General information

NPI: 1295913283
Provider Name (Legal Business Name): JERRY D. KING, O.D.
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 02/01/2008
Last Update Date: 02/01/2008
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

115 N OAK ST
ELDON MO
65026-1444
US

IV. Provider business mailing address

115 N OAK ST
ELDON MO
65026-1444
US

V. Phone/Fax

Practice location:
  • Phone: 573-392-7126
  • Fax:
Mailing address:
  • Phone: 573-392-7126
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code152W00000X
TaxonomyOptometrist
License Number
License Number State
# 2
Primary TaxonomyN
Taxonomy Code332B00000X
TaxonomyDurable Medical Equipment & Medical Supplies
License Number
License Number State

VIII. Authorized Official

Name: DR. JERRY D. KING
Title or Position: SOLE PROPRIETOR
Credential: O.D.
Phone: 573-392-7126