Provider Demographics
NPI:1780864322
Name:WHITEHOUSE, ROY WILSON III (OD)
Entity Type:Individual
Prefix:DR
First Name:ROY
Middle Name:WILSON
Last Name:WHITEHOUSE
Suffix:III
Gender:M
Credentials:OD
Other - Prefix:DR
Other - First Name:ROY
Other - Middle Name:W
Other - Last Name:WHITEHOUSE
Other - Suffix:
Other - Last Name Type:Professional Name
Other - Credentials:OD
Mailing Address - Street 1:PO BOX 396
Mailing Address - Street 2:
Mailing Address - City:BLACKSTONE
Mailing Address - State:VA
Mailing Address - Zip Code:23824-0396
Mailing Address - Country:US
Mailing Address - Phone:434-292-3696
Mailing Address - Fax:
Practice Address - Street 1:401 CHURCH ST
Practice Address - Street 2:
Practice Address - City:BLACKSTONE
Practice Address - State:VA
Practice Address - Zip Code:23824-1603
Practice Address - Country:US
Practice Address - Phone:434-292-3696
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2007-11-12
Last Update Date:2007-11-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
VA0618001033152W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes152W00000XEye and Vision Services ProvidersOptometrist
Provider Identifiers
StateIdentifier IDID TypeIssuer
VA039810OtherANTHEM BCBS
VA039810OtherANTHEM BCBS
VAU26738Medicare UPIN