Provider Demographics
NPI:1215955570
Name:KING, CHRISTIAN A (OD)
Entity type:Individual
Prefix:MR
First Name:CHRISTIAN
Middle Name:A
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 1:1001 S DEFIANCE ST
Mailing Address - Street 2:P.O. BOX 38
Mailing Address - City:ARCHBOLD
Mailing Address - State:OH
Mailing Address - Zip Code:43502-1617
Mailing Address - Country:US
Mailing Address - Phone:419-445-5436
Mailing Address - Fax:419-446-4818
Practice Address - Street 1:1001 S DEFIANCE ST
Practice Address - Street 2:1001 SOUTH DEFIANCE ST
Practice Address - City:ARCHBOLD
Practice Address - State:OH
Practice Address - Zip Code:43502-1617
Practice Address - Country:US
Practice Address - Phone:419-445-5436
Practice Address - Fax:419-446-4818
Is Sole Proprietor?:Yes
Enumeration Date:2006-07-17
Last Update Date:2008-09-25
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OH611174299152W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes152W00000XEye and Vision Services ProvidersOptometrist
Provider Identifiers
StateIdentifier IDID TypeIssuer
OH0768129Medicaid
KI0655791OtherADMINISTAR
0716620001OtherPALMETTO GBA
0716620001OtherPALMETTO GBA
OH0768129Medicaid