Healthcare Provider Details

I. General information

NPI: 1609552041
Provider Name (Legal Business Name): COURTNEY WHITLOCK OD
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 06/22/2023
Last Update Date: 06/26/2023
Certification Date: 06/26/2023
Deactivation Date:
Reactivation Date:

III. Provider practice location address

3440 S NATIONAL AVE
SPRINGFIELD MO
65807-7307
US

IV. Provider business mailing address

2242 S FARM ROAD 199
SPRINGFIELD MO
65809-3172
US

V. Phone/Fax

Practice location:
  • Phone: 417-221-8913
  • Fax:
Mailing address:
  • Phone: 417-880-2771
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code152W00000X
TaxonomyOptometrist
License Number2023021524
License Number StateMO

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: