Provider Demographics
NPI:1699751024
Name:KING, EVERETT LYLE (OD, FAAO)
Entity type:Individual
Prefix:DR
First Name:EVERETT
Middle Name:LYLE
Last Name:KING
Suffix:
Gender:M
Credentials:OD, FAAO
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:418 S 5TH ST
Mailing Address - Street 2:
Mailing Address - City:LARAMIE
Mailing Address - State:WY
Mailing Address - Zip Code:82070-3733
Mailing Address - Country:US
Mailing Address - Phone:307-745-8554
Mailing Address - Fax:307-755-5929
Practice Address - Street 1:418 S 5TH ST
Practice Address - Street 2:
Practice Address - City:LARAMIE
Practice Address - State:WY
Practice Address - Zip Code:82070-3733
Practice Address - Country:US
Practice Address - Phone:307-745-8554
Practice Address - Fax:307-755-5929
Is Sole Proprietor?:No
Enumeration Date:2005-12-18
Last Update Date:2014-05-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WYWYOMING 143T152WC0802X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes152WC0802XEye and Vision Services ProvidersOptometristCorneal and Contact Management
Provider Identifiers
StateIdentifier IDID TypeIssuer
WY104080400Medicaid
WY83-0324373OtherTAX ID
WYW22629Medicare PIN
WY104080400Medicaid