Provider Demographics
NPI:1235212457
Name:WHITAKER, DICK (OD)
Entity Type:Individual
Prefix:DR
First Name:DICK
Middle Name:
Last Name:WHITAKER
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 1:210 SERIO BLVD
Mailing Address - Street 2:
Mailing Address - City:FERRIDAY
Mailing Address - State:LA
Mailing Address - Zip Code:71334-2015
Mailing Address - Country:US
Mailing Address - Phone:318-757-3440
Mailing Address - Fax:318-757-3446
Practice Address - Street 1:210 SERIO BLVD
Practice Address - Street 2:
Practice Address - City:FERRIDAY
Practice Address - State:LA
Practice Address - Zip Code:71334-2015
Practice Address - Country:US
Practice Address - Phone:318-757-3440
Practice Address - Fax:318-757-3446
Is Sole Proprietor?:Yes
Enumeration Date:2006-10-23
Last Update Date:2020-06-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
LA1060-169T152W00000X
MS564152W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes152W00000XEye and Vision Services ProvidersOptometrist
Provider Identifiers
StateIdentifier IDID TypeIssuer
721149589OtherTENET CHOICES HUMANA
MS00087047Medicaid
0133910002OtherMEDICARE PALMETTO
LA1388734Medicaid
721149589OtherUNITED HEALTHCARE
LA2302BOtherBLUE CROSS OF LA
0133910002OtherMEDICARE PALMETTO
0133910002OtherMEDICARE PALMETTO
LA410037632Medicare PIN
0133910002Medicare NSC
MS$$$$$$$$$OtherBLUE CROSS OF MS
721149589OtherUNITED HEALTHCARE
LA48901Medicare PIN