Provider Demographics
NPI:1033494182
Name:WHITLEY, WARREN (OD)
Entity Type:Individual
Prefix:
First Name:WARREN
Middle Name:
Last Name:WHITLEY
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 1:2285 GREEN VISTA DR
Mailing Address - Street 2:
Mailing Address - City:SPARKS
Mailing Address - State:NV
Mailing Address - Zip Code:89431-1071
Mailing Address - Country:US
Mailing Address - Phone:775-674-1100
Mailing Address - Fax:
Practice Address - Street 1:2285 GREEN VISTA DR
Practice Address - Street 2:
Practice Address - City:SPARKS
Practice Address - State:NV
Practice Address - Zip Code:89431-1071
Practice Address - Country:US
Practice Address - Phone:775-674-1100
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2011-10-19
Last Update Date:2015-01-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
390200000X
NV810152W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes152W00000XEye and Vision Services ProvidersOptometrist
No390200000XStudent, Health CareStudent in an Organized Health Care Education/Training Program