Provider Demographics
NPI:1407840754
Name:WHITTLESEY, KIRK C
Entity Type:Individual
Prefix:
First Name:KIRK
Middle Name:C
Last Name:WHITTLESEY
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:P O BOX 648
Mailing Address - Street 2:12 TAFT ST S
Mailing Address - City:HUMBOLDT
Mailing Address - State:IA
Mailing Address - Zip Code:50548-2037
Mailing Address - Country:US
Mailing Address - Phone:515-332-2950
Mailing Address - Fax:515-332-4451
Practice Address - Street 1:12 TAFT ST S
Practice Address - Street 2:
Practice Address - City:HUMBOLDT
Practice Address - State:IA
Practice Address - Zip Code:50548-2037
Practice Address - Country:US
Practice Address - Phone:515-332-2950
Practice Address - Fax:515-332-4451
Is Sole Proprietor?:Yes
Enumeration Date:2005-09-01
Last Update Date:2012-11-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IA1581152W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes152W00000XEye and Vision Services ProvidersOptometrist
Provider Identifiers
StateIdentifier IDID TypeIssuer
IA0226282Medicaid
1581OtherALL OTHER HEALTH CARE
IA2262820OtherBCBS
410012199OtherRR MEDICARE
22628Medicare ID - Type Unspecified