Provider Demographics
NPI:1528075116
Name:KING, SHANE PATRICK (OD)
Entity type:Individual
Prefix:
First Name:SHANE
Middle Name:PATRICK
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 1:2679 REYNOLDS CIR
Mailing Address - Street 2:
Mailing Address - City:COLUMBIAVILLE
Mailing Address - State:MI
Mailing Address - Zip Code:48421-8935
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:523 M L KING AVE
Practice Address - Street 2:
Practice Address - City:FLINT
Practice Address - State:MI
Practice Address - Zip Code:48502-2002
Practice Address - Country:US
Practice Address - Phone:810-238-0925
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2006-08-03
Last Update Date:2009-12-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI4901004228152W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes152W00000XEye and Vision Services ProvidersOptometrist
Provider Identifiers
StateIdentifier IDID TypeIssuer
MI4901004228OtherLICENSE NUMBER
MI4901004228OtherLICENSE NUMBER
MIU99520Medicare UPIN
MI4922670001Medicare NSC