Provider Demographics
NPI:1720136435
Name:WHITELEY, SANDRA (OD)
Entity Type:Individual
Prefix:DR
First Name:SANDRA
Middle Name:
Last Name:WHITELEY
Suffix:
Gender:F
Credentials:OD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:303 E MAIN ST
Mailing Address - Street 2:
Mailing Address - City:LOWELL
Mailing Address - State:IN
Mailing Address - Zip Code:46356-1711
Mailing Address - Country:US
Mailing Address - Phone:219-696-7191
Mailing Address - Fax:219-696-8551
Practice Address - Street 1:303 E MAIN ST
Practice Address - Street 2:
Practice Address - City:LOWELL
Practice Address - State:IN
Practice Address - Zip Code:46356-1711
Practice Address - Country:US
Practice Address - Phone:219-696-7191
Practice Address - Fax:219-696-8551
Is Sole Proprietor?:Yes
Enumeration Date:2007-01-08
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IN18002411B152W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes152W00000XEye and Vision Services ProvidersOptometrist
Provider Identifiers
StateIdentifier IDID TypeIssuer
625600Medicare ID - Type Unspecified
INT-83816Medicare UPIN