Active NPI
Jerry Lee King, O.D.
- Optometrist
- Longview, TX
National Provider Identifier
1417020462
On this page
Key facts
NPPES NPI Registry- Primary specialty
- Optometrist
- License
- 2926TG
- Practice address
- 103 W Loop 281
Ste 450
Longview, TX 75605-4653 - Phone
- (903) 663-2020
- Fax
- (903) 663-2353
- NPI assigned
- Nov 16, 2006
- Last updated
- Jul 23, 2008
- Sex
- Male
- Sole proprietor
- Yes
NPPES NPI Registry
Registry information is reported by the provider to CMS and is not verified. About this source
Specialties & licenses 1
| Specialty (taxonomy) | Code | License | State | Primary |
|---|---|---|---|---|
| Optometrist | 152W00000X | 2926TG | TX | Primary |
Addresses
Primary practice location
103 W Loop 281
Ste 450
Longview, TX 75605-4653
Mailing address
103 W Loop 281
Suite 450
Longview, TX 75605-4653
Phone (903) 663-2020
Other identifiers 1
| Identifier | Type | State | Issuer |
|---|---|---|---|
| 093291502 | Medicaid | TX |
Medicare participation
Medicare enrollment files- Medicare fee-for-service enrollment
- Enrolled in TX
- Eligible to order & refer
- Part B services: Yes
- Medical equipment: Yes
- Home health: Yes
- Power mobility devices: No
- Hospice: Yes
Enrollment records 1
| Enrollment ID | State | Provider type | PAC ID | Details |
|---|---|---|---|---|
| I20040406001213 | TX | Practitioner - Optometry | 9335132208 | Practice locations: Henderson, TX |
National Provider Directory
National Provider Directory- Medicare enrollment (NPD)
- Enrolled
State licenses
| License | State | Type | Specialty |
|---|---|---|---|
| 2926TG | TX | MD | Optometrist |
Practice roles
| Organization | Specialty | Status | New patients |
|---|---|---|---|
| Amwallace, LLC | Optometrist | Past | Accepting new patients |
| Elk Vision Holdings LLC | Optometrist | Past | Accepting new patients |
Organizations & group practices 2
Organizations this provider is connected to: Medicare benefit reassignments (the organization bills Medicare for this provider’s services), Care Compare group memberships, National Provider Directory roles and organizations whose NPPES authorized official is this provider.
NPI Registry JSON
The complete NPPES record for this NPI in the NPI Registry API format.
{
"created_epoch": "1163635200000",
"enumeration_type": "NPI-1",
"last_updated_epoch": "1216771200000",
"number": "1417020462",
"addresses": [
{
"country_code": "US",
"country_name": "United States",
"address_purpose": "MAILING",
"address_type": "DOM",
"address_1": "103 W LOOP 281",
"address_2": "SUITE 450",
"city": "LONGVIEW",
"state": "TX",
"postal_code": "756054653",
"telephone_number": "903-663-2020",
"fax_number": "903-663-2353"
},
{
"country_code": "US",
"country_name": "United States",
"address_purpose": "LOCATION",
"address_type": "DOM",
"address_1": "103 W LOOP 281",
"address_2": "STE 450",
"city": "LONGVIEW",
"state": "TX",
"postal_code": "756054653",
"telephone_number": "903-663-2020",
"fax_number": "903-663-2353"
}
],
"practiceLocations": [],
"basic": {
"last_name": "KING",
"first_name": "JERRY",
"middle_name": "LEE",
"name_prefix": "Dr.",
"credential": "O.D.",
"sole_proprietor": "YES",
"sex": "M",
"enumeration_date": "2006-11-16",
"last_updated": "2008-07-23",
"status": "A"
},
"taxonomies": [
{
"code": "152W00000X",
"taxonomy_group": "",
"desc": "Optometrist",
"state": "TX",
"license": "2926TG",
"primary": true
}
],
"identifiers": [
{
"code": "05",
"desc": "MEDICAID",
"issuer": null,
"identifier": "093291502",
"state": "TX"
}
],
"endpoints": [],
"other_names": []
}Other providers in Longview, TX
Sources for this page
- NPPES NPI Registry (CMS): identity, addresses, specialties, licenses, identifiers and endpoints. Last updated by the provider on Jul 23, 2008; self-reported and not verified by CMS. Specialty names from the NUCC taxonomy.
- Medicare enrollment (CMS PECOS): enrollments, PAC IDs and benefit reassignments; Order and Referring.
- National Provider Directory (CMS): practice roles, locations, licenses, networks and endpoints.