Healthcare Provider Details

I. General information

NPI: 1912903162
Provider Name (Legal Business Name): OLIVER WENDELL WHITNEY OD
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 06/22/2005
Last Update Date: 12/19/2010
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1580 W CAUSEWAY APPROACH STE 3
MANDEVILLE LA
70471-3033
US

IV. Provider business mailing address

PO BOX 879
MANDEVILLE LA
70470-0879
US

V. Phone/Fax

Practice location:
  • Phone: 985-626-5242
  • Fax:
Mailing address:
  • Phone: 985-626-5242
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code152W00000X
TaxonomyOptometrist
License Number810300T
License Number StateLA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: