Provider Demographics
NPI:1407881725
Name:WHALEY, KEITH EDWARD (OD)
Entity Type:Individual
Prefix:DR
First Name:KEITH
Middle Name:EDWARD
Last Name:WHALEY
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 1:2541 SAND PIKE BLVD
Mailing Address - Street 2:
Mailing Address - City:PIGEON FORGE
Mailing Address - State:TN
Mailing Address - Zip Code:37863-6205
Mailing Address - Country:US
Mailing Address - Phone:865-428-0959
Mailing Address - Fax:865-429-0923
Practice Address - Street 1:2541 SAND PIKE BLVD
Practice Address - Street 2:
Practice Address - City:PIGEON FORGE
Practice Address - State:TN
Practice Address - Zip Code:37863-6205
Practice Address - Country:US
Practice Address - Phone:865-428-0959
Practice Address - Fax:865-429-0923
Is Sole Proprietor?:No
Enumeration Date:2006-07-12
Last Update Date:2012-05-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TNOD1729152W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes152W00000XEye and Vision Services ProvidersOptometrist
Provider Identifiers
StateIdentifier IDID TypeIssuer
TN3940567Medicaid
TN621651733OtherCHAMPVA
TN621651733OtherUNITED HEALTHCARE
TN621651733OtherCARITEN
TN621651733OtherCIGNA HEALTHCARE
TN621651733OtherHUMANA
TN621651733OtherJOHN DEERE HEALTHCARE
TN3041669OtherBCBS
TN621651733OtherTRICARE FOR LIFE
TN621651733OtherTRICARE FOR LIFE
TN3940567Medicare PIN