MEDICARE: DR. KENNETH WILLIAM KING JR. O.D.

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	152WC0802X	Corneal and Contact Management Optometrist	ODP0467	ID

Other Identifiers

#	Provider Identifier	Provider Identifier Type	Provider Identifier State	Provider Identifier Issuer
1	I-902428	OTHER		CHAMPUS
2	0605250001	OTHER		DMERC
3	82052	OTHER	ID	BLUE SHIELD
4	MEDICAID ID Found: Get Medicaid Details using Online Medicaid Verification Program

General Provider Information

NPI Number	:	1174524722
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	DR. KENNETH WILLIAM KING JR. O.D.

Provider Business Mailing Address
First Line	:	1480 E LINCOLN RD
Second Line	:
City	:	IDAHO FALLS
State	:	ID
Zip	:	83401-2128
Country	:	US
Telephone Number	:	208-525-8686
Fax Number	:	208-525-8684

Provider Business Practice Location Address
First Line	:	1480 E LINCOLN RD
Second Line	:
City	:	IDAHO FALLS
State	:	ID
Zip	:	83401-2128
Country	:	US
Telephone Number	:	208-525-8686
Fax Number	:	208-525-8684

Authorized Official
Title or Position	:
Name	:
Credential	:
Telephone Number	:

Provider Enumeration Date	:	08/04/2005
Last Update Date	:	12/20/2013

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