Basic Information
| Provider Information | |||||||||
| NPI: | 1548780133 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | KING -GOVE | ||||||||
| FirstName: | MOLLY | ||||||||
| MiddleName: | JOAN | ||||||||
| NamePrefix: | DR. | ||||||||
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| Credential: | OD | ||||||||
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| Mailing Information | |||||||||
| Address1: | 40 ROCKINGHAM AVE APT 204 | ||||||||
| Address2: | |||||||||
| City: | WEST ROXBURY | ||||||||
| State: | MA | ||||||||
| PostalCode: | 021324523 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 9082686480 | ||||||||
| FaxNumber: | |||||||||
| Practice Location | |||||||||
| Address1: | 468 HOSPITAL DR | ||||||||
| Address2: | |||||||||
| City: | ST JOHNSBURY | ||||||||
| State: | VT | ||||||||
| PostalCode: | 058199225 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8022237723 | ||||||||
| FaxNumber: | |||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 06/23/2017 | ||||||||
| LastUpdateDate: | 12/04/2020 | ||||||||
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| ProviderGenderCode: | F | ||||||||
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| IsSoleProprietor: | Y | ||||||||
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| NPICertificationDate: | 12/04/2020 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 152W00000X | 030.0133932 | VT | N | Eye and Vision Services Providers | Optometrist | 390200000X | N | Student, Health Care | Student in an Organized Health Care Education/Training Program | 152W00000X | 5241 | MA | Y | 193400000X SINGLE SPECIALTY GROUP | Eye and Vision Services Providers | Optometrist |
No ID Information.