Healthcare Provider Details

I. General information

NPI: 1588096432
Provider Name (Legal Business Name): ANDREW SCOTT WHITLEY O.D.
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 08/02/2013
Last Update Date: 07/27/2022
Certification Date: 07/27/2022
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1901 W UNIVERSITY BLVD
DURANT OK
74701-3098
US

IV. Provider business mailing address

PO BOX 1426
DURANT OK
74702-1426
US

V. Phone/Fax

Practice location:
  • Phone: 580-920-2020
  • Fax: 580-924-5656
Mailing address:
  • Phone: 580-920-2020
  • Fax: 580-924-2626

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code152W00000X
TaxonomyOptometrist
License Number1937DT
License Number StateKY
# 2
Primary TaxonomyN
Taxonomy Code152W00000X
TaxonomyOptometrist
License Number18003816A
License Number StateIN
# 3
Primary TaxonomyY
Taxonomy Code152W00000X
TaxonomyOptometrist
License Number2832
License Number StateOK

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: