Provider Demographics
NPI:1831287358
Name:WHITESIDE, LEONARD BRINKLEY III (OD)
Entity Type:Individual
Prefix:
First Name:LEONARD
Middle Name:BRINKLEY
Last Name:WHITESIDE
Suffix:III
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 1:400 WESTHAMPTON STA
Mailing Address - Street 2:
Mailing Address - City:RICHMOND
Mailing Address - State:VA
Mailing Address - Zip Code:23226-3330
Mailing Address - Country:US
Mailing Address - Phone:804-287-4200
Mailing Address - Fax:804-287-4210
Practice Address - Street 1:12018 W BROAD ST
Practice Address - Street 2:SUITE 100
Practice Address - City:HENRICO
Practice Address - State:VA
Practice Address - Zip Code:23233-7689
Practice Address - Country:US
Practice Address - Phone:804-287-1380
Practice Address - Fax:804-287-1384
Is Sole Proprietor?:No
Enumeration Date:2006-10-10
Last Update Date:2012-03-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
VA0618000199152W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes152W00000XEye and Vision Services ProvidersOptometrist
Provider Identifiers
StateIdentifier IDID TypeIssuer
VA230283OtherANTHEM
VA410000651Medicare ID - Type Unspecified
VA230283OtherANTHEM