Healthcare Provider Details

I. General information

NPI: 1982615977
Provider Name (Legal Business Name): TERI K. WHITTAKER I OD
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 08/11/2006
Last Update Date: 06/25/2020
Certification Date: 06/25/2020
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2900 HORIZON DR STE 15
BRYANT AR
72022-9095
US

IV. Provider business mailing address

11225 HURON LN STE 200A
LITTLE ROCK AR
72211-1861
US

V. Phone/Fax

Practice location:
  • Phone: 504-653-2020
  • Fax: 501-653-7407
Mailing address:
  • Phone: 501-653-2020
  • Fax: 501-653-7407

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code152W00000X
TaxonomyOptometrist
License Number2573
License Number StateAR

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: