Provider Demographics
NPI:1891845186
Name:WHISENANT, JODY L (OD)
Entity Type:Individual
Prefix:
First Name:JODY
Middle Name:L
Last Name:WHISENANT
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 1:1276 JESSE JEWELL PKWY SE
Mailing Address - Street 2:
Mailing Address - City:GAINESVILLE
Mailing Address - State:GA
Mailing Address - Zip Code:30501-3823
Mailing Address - Country:US
Mailing Address - Phone:770-532-7246
Mailing Address - Fax:770-532-2683
Practice Address - Street 1:1276 JESSE JEWELL PKWY SE
Practice Address - Street 2:
Practice Address - City:GAINESVILLE
Practice Address - State:GA
Practice Address - Zip Code:30501-3823
Practice Address - Country:US
Practice Address - Phone:770-532-7246
Practice Address - Fax:770-532-2683
Is Sole Proprietor?:No
Enumeration Date:2007-01-11
Last Update Date:2008-02-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GA1035T152W00000X, 152WC0802X, 152WX0102X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes152W00000XEye and Vision Services ProvidersOptometrist
No152WC0802XEye and Vision Services ProvidersOptometristCorneal and Contact Management
No152WX0102XEye and Vision Services ProvidersOptometristOccupational Vision
Provider Identifiers
StateIdentifier IDID TypeIssuer
GA00461667AMedicaid
GACG8677OtherMEDICARE RAILROD GROUP
GA2230019OtherUNITED HEALTHCARE
GA300028600BMedicaid
GA537962OtherUS HEALTHCARE
GA1035TOtherGA STATE LICENSE
GAU36841Medicare UPIN
GA41ZCBLLMedicare ID - Type Unspecified
GA300028600BMedicaid