MEDICARE: DR. GLEN A WHITEHEAD O.D.

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	152W00000X	Optometrist	3096	OH
2	152WC0802X	Corneal and Contact Management Optometrist	3096	OH
3	152WP0200X	Pediatric Optometrist	3096	OH
4	152WS0006X	Sports Vision Optometrist	3096	OH
5	152WV0400X	Vision Therapy Optometrist	3096	OH

Other Identifiers

#	Provider Identifier	Provider Identifier Type	Provider Identifier State	Provider Identifier Issuer
1	MEDICAID ID Found: Get Medicaid Details using Online Medicaid Verification Program

General Provider Information

NPI Number	:	1669578456
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	DR. GLEN A WHITEHEAD O.D.

Provider Business Mailing Address
First Line	:	2762 HERMAN RD
Second Line	:
City	:	HAMILTON
State	:	OH
Zip	:	45013-9533
Country	:	US
Telephone Number	:	513-892-5961
Fax Number	:	513-892-5962

Provider Business Practice Location Address
First Line	:	2762 HERMAN RD
Second Line	:
City	:	HAMILTON
State	:	OH
Zip	:	45013-9533
Country	:	US
Telephone Number	:	513-892-5961
Fax Number	:	513-892-5962

Authorized Official
Title or Position	:
Name	:
Credential	:
Telephone Number	:

Provider Enumeration Date	:	09/16/2006
Last Update Date	:	03/10/2008

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Directions to “ DR. GLEN A WHITEHEAD O.D.” Practice Location

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