MEDICARE: LEONARD BRINKLEY WHITESIDE III OD

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	152W00000X	Optometrist	0618000199	VA

Other Identifiers

#	Provider Identifier	Provider Identifier Type	Provider Identifier State	Provider Identifier Issuer
1	230283	OTHER	VA	ANTHEM

General Provider Information

NPI Number	:	1831287358
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	LEONARD BRINKLEY WHITESIDE III OD

Provider Business Mailing Address
First Line	:	400 WESTHAMPTON STA
Second Line	:
City	:	RICHMOND
State	:	VA
Zip	:	23226-3330
Country	:	US
Telephone Number	:	804-287-4200
Fax Number	:	804-287-4210

Provider Business Practice Location Address
First Line	:	12018 W BROAD ST
Second Line	:	SUITE 100
City	:	HENRICO
State	:	VA
Zip	:	23233-7689
Country	:	US
Telephone Number	:	804-287-1380
Fax Number	:	804-287-1384

Authorized Official
Title or Position	:
Name	:
Credential	:
Telephone Number	:

Provider Enumeration Date	:	10/10/2006
Last Update Date	:	03/22/2012

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