Healthcare Provider Details

I. General information

NPI: 1235212457
Provider Name (Legal Business Name): DICK WHITAKER OD
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 10/23/2006
Last Update Date: 06/17/2020
Certification Date: 06/17/2020
Deactivation Date:
Reactivation Date:

III. Provider practice location address

210 SERIO BLVD
FERRIDAY LA
71334-2015
US

IV. Provider business mailing address

210 SERIO BLVD
FERRIDAY LA
71334-2015
US

V. Phone/Fax

Practice location:
  • Phone: 318-757-3440
  • Fax: 318-757-3446
Mailing address:
  • Phone: 318-757-3440
  • Fax: 318-757-3446

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code152W00000X
TaxonomyOptometrist
License Number1060-169T
License Number StateLA
# 2
Primary TaxonomyY
Taxonomy Code152W00000X
TaxonomyOptometrist
License Number564
License Number StateMS

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: