Basic Information
| Provider Information | |||||||||
| NPI: | 1235390907 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | KING | ||||||||
| FirstName: | JEREMY | ||||||||
| MiddleName: | DAVID | ||||||||
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| Credential: | O.D. | ||||||||
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| Mailing Information | |||||||||
| Address1: | 15951 LITTLE AXE DR | ||||||||
| Address2: | |||||||||
| City: | NORMAN | ||||||||
| State: | OK | ||||||||
| PostalCode: | 730269088 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 4057017900 | ||||||||
| FaxNumber: | 4057017914 | ||||||||
| Practice Location | |||||||||
| Address1: | 15702 EAST HIGHWAY 9 | ||||||||
| Address2: | |||||||||
| City: | NORMAN | ||||||||
| State: | OK | ||||||||
| PostalCode: | 73026 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 4054470300 | ||||||||
| FaxNumber: | 4057017914 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 06/24/2008 | ||||||||
| LastUpdateDate: | 12/05/2016 | ||||||||
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| ProviderGenderCode: | M | ||||||||
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| IsSoleProprietor: | N | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 152W00000X | OK2535 | OK | Y | Eye and Vision Services Providers | Optometrist |
ID Information
| ID | Type | State | Issuer | Description | 200222240A | 05 | OK | MEDICAID |