MEDICARE: SHANE PATRICK KING 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	152W00000X	Optometrist	4901004228	MI

Other Identifiers

#	Provider Identifier	Provider Identifier Type	Provider Identifier State	Provider Identifier Issuer
1	4901004228	OTHER	MI	LICENSE NUMBER

General Provider Information

NPI Number	:	1528075116
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	SHANE PATRICK KING O.D.

Provider Business Mailing Address
First Line	:	2679 REYNOLDS CIR
Second Line	:
City	:	COLUMBIAVILLE
State	:	MI
Zip	:	48421-8935
Country	:	US
Telephone Number	:
Fax Number	:

Provider Business Practice Location Address
First Line	:	523 M L KING AVE
Second Line	:
City	:	FLINT
State	:	MI
Zip	:	48502-2002
Country	:	US
Telephone Number	:	810-238-0925
Fax Number	:

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

Provider Enumeration Date	:	08/03/2006
Last Update Date	:	12/17/2009

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