Provider Demographics
NPI:1720009723
Name:WEATHERHOLT, OTIS VICTOR (OD)
Entity Type:Individual
Prefix:
First Name:OTIS
Middle Name:VICTOR
Last Name:WEATHERHOLT
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 1:1912 GRAVES MILL RD
Mailing Address - Street 2:
Mailing Address - City:LYNCHBURG
Mailing Address - State:VA
Mailing Address - Zip Code:24502-4237
Mailing Address - Country:US
Mailing Address - Phone:434-385-7898
Mailing Address - Fax:434-385-1421
Practice Address - Street 1:1912 GRAVES MILL RD
Practice Address - Street 2:
Practice Address - City:LYNCHBURG
Practice Address - State:VA
Practice Address - Zip Code:24502-4237
Practice Address - Country:US
Practice Address - Phone:434-385-7898
Practice Address - Fax:434-385-1421
Is Sole Proprietor?:Yes
Enumeration Date:2006-07-22
Last Update Date:2011-10-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
VA0618000350152W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes152W00000XEye and Vision Services ProvidersOptometrist
Provider Identifiers
StateIdentifier IDID TypeIssuer
VA009200703Medicaid
VAU24696Medicare UPIN
VA410000266Medicare PIN