Provider Demographics
NPI:1205825270
Name:WHEADON, DONALD W (OD)
Entity Type:Individual
Prefix:DR
First Name:DONALD
Middle Name:W
Last Name:WHEADON
Suffix:
Gender:M
Credentials:OD
Other - Prefix:DR
Other - First Name:D.
Other - Middle Name:WES
Other - Last Name:WHEADON
Other - Suffix:
Other - Last Name Type:Professional Name
Other - Credentials:OD
Mailing Address - Street 1:8240 SANTA MONICA BLVD
Mailing Address - Street 2:
Mailing Address - City:WEST HOLLYWOOD
Mailing Address - State:CA
Mailing Address - Zip Code:90046-5916
Mailing Address - Country:US
Mailing Address - Phone:323-654-5600
Mailing Address - Fax:323-654-5614
Practice Address - Street 1:8240 SANTA MONICA BLVD
Practice Address - Street 2:
Practice Address - City:WEST HOLLYWOOD
Practice Address - State:CA
Practice Address - Zip Code:90046-5916
Practice Address - Country:US
Practice Address - Phone:323-654-5600
Practice Address - Fax:323-654-5614
Is Sole Proprietor?:Yes
Enumeration Date:2005-10-20
Last Update Date:2017-12-04
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA0005481TLG152W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes152W00000XEye and Vision Services ProvidersOptometrist
Provider Identifiers
StateIdentifier IDID TypeIssuer
CAFT048AMedicare PIN
CAT10006Medicare UPIN