Provider Demographics
NPI:1194714220
Name:KING, CHRISTOPHER BURNETTE (OD)
Entity type:Individual
Prefix:DR
First Name:CHRISTOPHER
Middle Name:BURNETTE
Last Name:KING
Suffix:
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 1:518 VINNEDGE RIDE
Mailing Address - Street 2:
Mailing Address - City:TALLAHASSEE
Mailing Address - State:FL
Mailing Address - Zip Code:32303-5142
Mailing Address - Country:US
Mailing Address - Phone:850-556-3290
Mailing Address - Fax:850-893-9987
Practice Address - Street 1:4400 W TENNESSEE ST
Practice Address - Street 2:
Practice Address - City:TALLAHASSEE
Practice Address - State:FL
Practice Address - Zip Code:32304-1029
Practice Address - Country:US
Practice Address - Phone:850-574-6113
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2005-10-20
Last Update Date:2016-12-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FL1845152W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes152W00000XEye and Vision Services ProvidersOptometrist
Provider Identifiers
StateIdentifier IDID TypeIssuer
FL078311100Medicaid
FL078311100Medicaid
FLT84184Medicare UPIN