Provider Demographics
NPI:1659483857
Name:WHITTAKER, KAY SHIN SUSANNA (OD)
Entity Type:Individual
Prefix:
First Name:KAY SHIN
Middle Name:SUSANNA
Last Name:WHITTAKER
Suffix:
Gender:F
Credentials:OD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:121 S 3RD ST
Mailing Address - Street 2:
Mailing Address - City:SABETHA
Mailing Address - State:KS
Mailing Address - Zip Code:66534-2411
Mailing Address - Country:US
Mailing Address - Phone:785-285-1349
Mailing Address - Fax:
Practice Address - Street 1:1002 MAIN ST
Practice Address - Street 2:
Practice Address - City:SABETHA
Practice Address - State:KS
Practice Address - Zip Code:66534-1831
Practice Address - Country:US
Practice Address - Phone:785-284-2139
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2006-09-01
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
KS1701152W00000X
TX5788T152W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes152W00000XEye and Vision Services ProvidersOptometrist