Healthcare Provider Details

I. General information

NPI: 1669578456
Provider Name (Legal Business Name): GLEN A WHITEHEAD O.D.
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 09/16/2006
Last Update Date: 03/10/2008
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2762 HERMAN RD
HAMILTON OH
45013-9533
US

IV. Provider business mailing address

2762 HERMAN RD
HAMILTON OH
45013-9533
US

V. Phone/Fax

Practice location:
  • Phone: 513-892-5961
  • Fax: 513-892-5962
Mailing address:
  • Phone: 513-892-5961
  • Fax: 513-892-5962

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code152W00000X
TaxonomyOptometrist
License Number3096
License Number StateOH
# 2
Primary TaxonomyN
Taxonomy Code152WC0802X
TaxonomyCorneal and Contact Management Optometrist
License Number3096
License Number StateOH
# 3
Primary TaxonomyN
Taxonomy Code152WP0200X
TaxonomyPediatric Optometrist
License Number3096
License Number StateOH
# 4
Primary TaxonomyN
Taxonomy Code152WS0006X
TaxonomySports Vision Optometrist
License Number3096
License Number StateOH
# 5
Primary TaxonomyN
Taxonomy Code152WV0400X
TaxonomyVision Therapy Optometrist
License Number3096
License Number StateOH

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: