Basic Information
| Provider Information | |||||||||
| NPI: | 1386636538 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | KING | ||||||||
| FirstName: | KEVIN | ||||||||
| MiddleName: | M | ||||||||
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| NameSuffix: | |||||||||
| Credential: | MD | ||||||||
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| Mailing Information | |||||||||
| Address1: | 1000 RANDALL RD STE 100 | ||||||||
| Address2: | |||||||||
| City: | GENEVA | ||||||||
| State: | IL | ||||||||
| PostalCode: | 601342591 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 6302321282 | ||||||||
| FaxNumber: | 6302327011 | ||||||||
| Practice Location | |||||||||
| Address1: | 1000 RANDALL RD STE 100 | ||||||||
| Address2: | |||||||||
| City: | GENEVA | ||||||||
| State: | IL | ||||||||
| PostalCode: | 601342591 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 6302321282 | ||||||||
| FaxNumber: | 6302327011 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 08/15/2005 | ||||||||
| LastUpdateDate: | 01/03/2020 | ||||||||
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| ProviderGenderCode: | M | ||||||||
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| IsSoleProprietor: | N | ||||||||
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| NPICertificationDate: | 01/03/2020 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 207W00000X | 036-083777 | IL | Y | Allopathic & Osteopathic Physicians | Ophthalmology |
ID Information
| ID | Type | State | Issuer | Description | 036083777 | 05 | IL | MEDICAID |