Provider Demographics
NPI:1710980107
Name:WHITTINGTON, JEFFERY LEE (OD)
Entity Type:Individual
Prefix:DR
First Name:JEFFERY
Middle Name:LEE
Last Name:WHITTINGTON
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 1:25 SENECA HILLS
Mailing Address - Street 2:
Mailing Address - City:ELKVIEW
Mailing Address - State:WV
Mailing Address - Zip Code:25071
Mailing Address - Country:US
Mailing Address - Phone:304-965-6630
Mailing Address - Fax:304-344-5483
Practice Address - Street 1:3840 PENNSYLVANIA AVE
Practice Address - Street 2:
Practice Address - City:CHARLESTON
Practice Address - State:WV
Practice Address - Zip Code:25302-4650
Practice Address - Country:US
Practice Address - Phone:304-342-0660
Practice Address - Fax:304-344-5483
Is Sole Proprietor?:No
Enumeration Date:2005-05-31
Last Update Date:2008-02-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WV765-OD152W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes152W00000XEye and Vision Services ProvidersOptometrist
Provider Identifiers
StateIdentifier IDID TypeIssuer
WV0150926000Medicaid
WV0150926000Medicaid
WVWH4167001Medicare PIN
WVT32598Medicare UPIN