Provider Demographics
NPI:1194713990
Name:KING, HOLTON S JR (OD)
Entity type:Individual
Prefix:DR
First Name:HOLTON
Middle Name:S
Last Name:KING
Suffix:JR
Gender:M
Credentials:OD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:118 VISION DR
Mailing Address - Street 2:
Mailing Address - City:CORNELIA
Mailing Address - State:GA
Mailing Address - Zip Code:30531-5737
Mailing Address - Country:US
Mailing Address - Phone:706-776-6311
Mailing Address - Fax:706-776-7243
Practice Address - Street 1:118 VISION DR
Practice Address - Street 2:
Practice Address - City:CORNELIA
Practice Address - State:GA
Practice Address - Zip Code:30531-5737
Practice Address - Country:US
Practice Address - Phone:706-776-6311
Practice Address - Fax:706-776-7243
Is Sole Proprietor?:No
Enumeration Date:2005-10-06
Last Update Date:2011-02-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GA1106152W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes152W00000XEye and Vision Services ProvidersOptometrist
Provider Identifiers
StateIdentifier IDID TypeIssuer
GA00515545BMedicaid
U20901Medicare UPIN
41ZCGJCMedicare PIN