Basic Information
| Provider Information | |||||||||
| NPI: | 1104025089 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | KING | ||||||||
| FirstName: | SHERALYN | ||||||||
| MiddleName: | KYLE | ||||||||
| NamePrefix: | DR. | ||||||||
| NameSuffix: | |||||||||
| Credential: | O.D. | ||||||||
| OtherOrganizationName: | |||||||||
| OtherOrganizationType: | |||||||||
| OtherLastName: | CERUTTI | ||||||||
| OtherFirstName: | SHERALYN | ||||||||
| OtherMiddleName: | KYLE | ||||||||
| OtherNamePrefix: | DR. | ||||||||
| OtherNameSuffix: | |||||||||
| OtherCredential: | O.D. | ||||||||
| OtherLastNameType: | 1 | ||||||||
| Mailing Information | |||||||||
| Address1: | 19336 LEITERSBURG PIKE | ||||||||
| Address2: | |||||||||
| City: | HAGERSTOWN | ||||||||
| State: | MD | ||||||||
| PostalCode: | 217421436 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7172637050 | ||||||||
| FaxNumber: | 7172633277 | ||||||||
| Practice Location | |||||||||
| Address1: | 1800 E MAIN ST | ||||||||
| Address2: | |||||||||
| City: | WAYNESBORO | ||||||||
| State: | PA | ||||||||
| PostalCode: | 172681879 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7177629178 | ||||||||
| FaxNumber: | |||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 07/12/2007 | ||||||||
| LastUpdateDate: | 03/17/2018 | ||||||||
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| ProviderGenderCode: | F | ||||||||
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| AuthorizedOfficialTitleorPosition: | |||||||||
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| IsSoleProprietor: | N | ||||||||
| IsOrganizationSubpart: | |||||||||
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| NPICertificationDate: | |||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 152W00000X | OEG001905 | PA | Y | Eye and Vision Services Providers | Optometrist |
ID Information
| ID | Type | State | Issuer | Description | 1019527740003 | 05 | PA | MEDICAID |