Provider Demographics
NPI:1548364722
Name:WHITTAKER, DOUGLAS (OD)
Entity type:Individual
Prefix:
First Name:DOUGLAS
Middle Name:
Last Name:WHITTAKER
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 1:121 S 3RD ST
Mailing Address - Street 2:
Mailing Address - City:SABETHA
Mailing Address - State:KS
Mailing Address - Zip Code:66534-2411
Mailing Address - Country:US
Mailing Address - Phone:785-285-0982
Mailing Address - Fax:
Practice Address - Street 1:1002 MAIN ST
Practice Address - Street 2:
Practice Address - City:SABETHA
Practice Address - State:KS
Practice Address - Zip Code:66534-1831
Practice Address - Country:US
Practice Address - Phone:785-284-2139
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2006-09-11
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
KS1700152W00000X
TX5793TG152W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes152W00000XEye and Vision Services ProvidersOptometrist
Provider Identifiers
StateIdentifier IDID TypeIssuer
02240293Medicare ID - Type Unspecified
TXU78469Medicare UPIN