Provider Demographics
NPI:1669578456
Name:WHITEHEAD, GLEN A (OD)
Entity type:Individual
Prefix:DR
First Name:GLEN
Middle Name:A
Last Name:WHITEHEAD
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 1:2762 HERMAN RD
Mailing Address - Street 2:
Mailing Address - City:HAMILTON
Mailing Address - State:OH
Mailing Address - Zip Code:45013-9533
Mailing Address - Country:US
Mailing Address - Phone:513-892-5961
Mailing Address - Fax:513-892-5962
Practice Address - Street 1:2762 HERMAN RD
Practice Address - Street 2:
Practice Address - City:HAMILTON
Practice Address - State:OH
Practice Address - Zip Code:45013-9533
Practice Address - Country:US
Practice Address - Phone:513-892-5961
Practice Address - Fax:513-892-5962
Is Sole Proprietor?:Yes
Enumeration Date:2006-09-16
Last Update Date:2008-03-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OH3096152W00000X, 152WC0802X, 152WP0200X, 152WS0006X, 152WV0400X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes152W00000XEye and Vision Services ProvidersOptometrist
No152WC0802XEye and Vision Services ProvidersOptometristCorneal and Contact Management
No152WP0200XEye and Vision Services ProvidersOptometristPediatrics
No152WS0006XEye and Vision Services ProvidersOptometristSports Vision
No152WV0400XEye and Vision Services ProvidersOptometristVision Therapy
Provider Identifiers
StateIdentifier IDID TypeIssuer
OH0227007Medicaid
OH0227007Medicaid
OHT46637Medicare UPIN