1629077649 NPI number — COLLEEN M KING O.D.

Table of content: COLLEEN M KING O.D. (NPI 1629077649)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1629077649 NPI number — COLLEEN M KING O.D.

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
Provider Last Name:
KING
Provider First Name:
COLLEEN
Provider Middle Name:
M
Provider Name Prefix Text:
Provider Name Suffix Text:
Provider Credential Text:
O.D.
Provider Gender Code:
F

Provider's Other Name Information

Provider Other Organization Name:
Provider Other Organization Name Type Code:
Provider Other Last Name:
Provider Other First Name:
Provider Other Middle Name:
Provider Other Name Prefix Text:
Provider Other Name Suffix Text:
Provider Other Credential Text:
Provider Other Last Name Type Code:

NPI Number Information

NPI Number:
1629077649
Entity Type Code:
Individual
Replacement NPI:
Last Update Date:
05/31/2022
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
201 N HOGAN ST STE 100
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
JACKSONVILLE
Provider Business Mailing Address State Name:
FL
Provider Business Mailing Address Postal Code:
32202-4203
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
904-356-9431
Provider Business Mailing Address Fax Number:
904-356-2969

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
201 N HOGAN ST STE 100
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
JACKSONVILLE
Provider Business Practice Location Address State Name:
FL
Provider Business Practice Location Address Postal Code:
32202-4203
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
904-356-9431
Provider Business Practice Location Address Fax Number:
904-356-2969
Provider Enumeration Date:
07/20/2005

Additional Information

Authorized Official

Authorized Official Last Name:
Authorized Official First Name:
Authorized Official Middle Name:
Authorized Official Title or Position:
Authorized Official Telephone Number:

Provider Taxonomy Codes

  • Taxonomy code: 152W00000X , with the licence number:  OPC3718 , registered in the state of FL ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

Other Provider's Identifiers (legacy, non-NPI)

  • Identifier: 0135179 . This is a "GHI" identifier . This identifiers is of the category "OTHER".
  • Identifier: 620893200 . This is a "MEDICAID INDIVIDUAL ID" identifier , issued by the state of ( FL ) . This identifiers is of the category "OTHER".
  • Identifier: 45002 . This is a "BCBS INDIVIDUAL" identifier , issued by the state of ( FL ) . This identifiers is of the category "OTHER".
  • Identifier: 26115561 . This is a "UNITED HEALTHCARE" identifier . This identifiers is of the category "OTHER".
  • Identifier: 7500506 . This is a "AETNA" identifier , issued by the state of ( FL ) . This identifiers is of the category "OTHER".
  • Identifier: 8700204 . This is a "CIGNA" identifier . This identifiers is of the category "OTHER".
  • Identifier: 620893200 . This is a "Florida Medicaid Provider ID" identifier , issued by the state of ( FL ) . This identifiers is of the category "MEDICAID".




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