Healthcare Provider Details

I. General information

NPI: 1285843524
Provider Name (Legal Business Name): JOHN B. WHITLOW, O.D.P.C.
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 05/22/2007
Last Update Date: 05/19/2011
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

407 S GREENWOOD ST
LAGRANGE GA
30240-3123
US

IV. Provider business mailing address

407 S GREENWOOD ST
LAGRANGE GA
30240-3123
US

V. Phone/Fax

Practice location:
  • Phone: 706-882-0616
  • Fax: 706-882-8515
Mailing address:
  • Phone: 706-882-0616
  • Fax: 706-882-8515

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code152W00000X
TaxonomyOptometrist
License NumberOPT001301
License Number StateGA

VIII. Authorized Official

Name: DR. DONNA GASKINS WHITLOW
Title or Position: SECRETARY
Credential: O.D.
Phone: 706-882-0616