Provider Demographics
NPI:1457501231
Name:VINCENT W. WHITE OD, INC.
Entity Type:Organization
Organization Name:VINCENT W. WHITE OD, INC.
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:DR
Authorized Official - First Name:VINCENT
Authorized Official - Middle Name:WILLIAM
Authorized Official - Last Name:WHITE
Authorized Official - Suffix:
Authorized Official - Credentials:OD
Authorized Official - Phone:818-779-0152
Mailing Address - Street 1:15230 BURBANK BLVD
Mailing Address - Street 2:# 109
Mailing Address - City:SHERMAN OAKS
Mailing Address - State:CA
Mailing Address - Zip Code:91411-3534
Mailing Address - Country:US
Mailing Address - Phone:818-779-0152
Mailing Address - Fax:818-779-0854
Practice Address - Street 1:15230 BURBANK BLVD
Practice Address - Street 2:# 109
Practice Address - City:SHERMAN OAKS
Practice Address - State:CA
Practice Address - Zip Code:91411-3534
Practice Address - Country:US
Practice Address - Phone:818-779-0152
Practice Address - Fax:818-779-0854
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2008-09-29
Last Update Date:2008-09-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes152W00000XEye and Vision Services ProvidersOptometristGroup - Single Specialty
No332H00000XSuppliersEyewear SupplierGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
CA1245259761Medicaid
CASD0053460Medicaid
CASD0053460Medicaid
CAOP5346Medicare PIN