Provider Demographics
NPI:1376385831
Name:WHITNEY, SHANE ROBERT (OD)
Entity type:Individual
Prefix:
First Name:SHANE
Middle Name:ROBERT
Last Name:WHITNEY
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 1:1885 JEWELL AVE APT 280
Mailing Address - Street 2:
Mailing Address - City:WINTER PARK
Mailing Address - State:FL
Mailing Address - Zip Code:32789-5585
Mailing Address - Country:US
Mailing Address - Phone:850-284-7742
Mailing Address - Fax:
Practice Address - Street 1:3226 E COLONIAL DR
Practice Address - Street 2:
Practice Address - City:ORLANDO
Practice Address - State:FL
Practice Address - Zip Code:32803-5110
Practice Address - Country:US
Practice Address - Phone:407-203-5801
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2024-06-06
Last Update Date:2024-07-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FL6472152W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes152W00000XEye and Vision Services ProvidersOptometrist