Provider Demographics
NPI:1003096629
Name:WHITMORE, SAMUEL P (OD)
Entity Type:Individual
Prefix:
First Name:SAMUEL
Middle Name:P
Last Name:WHITMORE
Suffix:
Gender:M
Credentials:OD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:3725 INGERSOLL AVE
Mailing Address - Street 2:
Mailing Address - City:DES MOINES
Mailing Address - State:IA
Mailing Address - Zip Code:50312-3410
Mailing Address - Country:US
Mailing Address - Phone:515-279-2020
Mailing Address - Fax:515-255-8002
Practice Address - Street 1:3735 86TH ST
Practice Address - Street 2:
Practice Address - City:URBANDALE
Practice Address - State:IA
Practice Address - Zip Code:50322-4008
Practice Address - Country:US
Practice Address - Phone:515-270-8545
Practice Address - Fax:515-270-0548
Is Sole Proprietor?:Yes
Enumeration Date:2007-11-12
Last Update Date:2013-09-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IA002398152W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes152W00000XEye and Vision Services ProvidersOptometrist