Healthcare Provider Details

I. General information

NPI: 1386614352
Provider Name (Legal Business Name): KENNETH JOHN WHITWELL O.D., MBA
Entity Type: Individual
Gender: Male
Sole Proprietor: X

II. Dates (important events)

Enumeration Date: 01/24/2006
Last Update Date: 07/08/2007
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

3259 CATLIN AVE
QUANTICO VA
22134-5109
US

IV. Provider business mailing address

3259 CATLIN AVE
QUANTICO VA
22134-5109
US

V. Phone/Fax

Practice location:
  • Phone: 703-784-1526
  • Fax: 703-784-1681
Mailing address:
  • Phone: 703-784-1526
  • Fax: 703-784-1681

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code152W00000X
TaxonomyOptometrist
License Number4025T
License Number StateOR

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: