Provider Demographics
NPI:1497758395
Name:WHITELEATHER, KEVIN A (OD)
Entity Type:Individual
Prefix:DR
First Name:KEVIN
Middle Name:A
Last Name:WHITELEATHER
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 1:4201 LAHMEYER RD
Mailing Address - Street 2:
Mailing Address - City:FORT WAYNE
Mailing Address - State:IN
Mailing Address - Zip Code:46815-5676
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:4201 LAHMEYER RD
Practice Address - Street 2:
Practice Address - City:FORT WAYNE
Practice Address - State:IN
Practice Address - Zip Code:46815-5676
Practice Address - Country:US
Practice Address - Phone:260-486-6106
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2005-05-24
Last Update Date:2007-10-26
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IN18003140A152W00000X, 152WL0500X, 152WC0802X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes152W00000XEye and Vision Services ProvidersOptometrist
No152WL0500XEye and Vision Services ProvidersOptometristLow Vision Rehabilitation
No152WC0802XEye and Vision Services ProvidersOptometristCorneal and Contact Management
Provider Identifiers
StateIdentifier IDID TypeIssuer
IN7470288OtherAETNA PROVIDER NUMBER
IN000000225758OtherANTHEM BC/BS PROVIDER NO.
IN7470288OtherAETNA PROVIDER NUMBER
INCJ3814Medicare ID - Type UnspecifiedRR MEDICARE GROUP NO.
IN0318800001Medicare NSC
IN000000225758OtherANTHEM BC/BS PROVIDER NO.