Provider Demographics
NPI:1013096122
Name:WHITTED, WILLIAM DALE (OD)
Entity Type:Individual
Prefix:DR
First Name:WILLIAM
Middle Name:DALE
Last Name:WHITTED
Suffix:
Gender:M
Credentials:OD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
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Other - Credentials:
Mailing Address - Street 1:1036 W ROBINHOOD DR
Mailing Address - Street 2:SUITE 105
Mailing Address - City:STOCKTON
Mailing Address - State:CA
Mailing Address - Zip Code:95207-5623
Mailing Address - Country:US
Mailing Address - Phone:209-951-3693
Mailing Address - Fax:209-951-4711
Practice Address - Street 1:1036 W ROBINHOOD DR
Practice Address - Street 2:SUITE 105
Practice Address - City:STOCKTON
Practice Address - State:CA
Practice Address - Zip Code:95207-5623
Practice Address - Country:US
Practice Address - Phone:209-951-3693
Practice Address - Fax:209-951-4711
Is Sole Proprietor?:Yes
Enumeration Date:2006-11-02
Last Update Date:2007-08-31
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA5969T152W00000X, 152WL0500X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes152W00000XEye and Vision Services ProvidersOptometrist
No152WL0500XEye and Vision Services ProvidersOptometristLow Vision Rehabilitation
Provider Identifiers
StateIdentifier IDID TypeIssuer
CASD0059690Medicare ID - Type Unspecified
CAT10185Medicare UPIN