Provider Demographics
NPI:1144385105
Name:WITAKER, VALERIE (OD)
Entity Type:Individual
Prefix:
First Name:VALERIE
Middle Name:
Last Name:WITAKER
Suffix:
Gender:F
Credentials:OD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:11103 WEST AVE
Mailing Address - Street 2:SUITE 6
Mailing Address - City:SAN ANTONIO
Mailing Address - State:TX
Mailing Address - Zip Code:78213-1370
Mailing Address - Country:US
Mailing Address - Phone:210-524-6509
Mailing Address - Fax:210-524-6587
Practice Address - Street 1:825 DULANEY VALLEY RD
Practice Address - Street 2:SUITE 1335
Practice Address - City:TOWSON
Practice Address - State:MD
Practice Address - Zip Code:21204-1010
Practice Address - Country:US
Practice Address - Phone:301-590-9191
Practice Address - Fax:301-590-3971
Is Sole Proprietor?:No
Enumeration Date:2006-12-27
Last Update Date:2007-07-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MDTA1416152W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes152W00000XEye and Vision Services ProvidersOptometrist
Provider Identifiers
StateIdentifier IDID TypeIssuer
MDU90476Medicare UPIN
MD501M1750Medicare ID - Type UnspecifiedMEDICARE