Provider Demographics
NPI:1750376414
Name:WHITLOW, JOHN B (OD)
Entity type:Individual
Prefix:DR
First Name:JOHN
Middle Name:B
Last Name:WHITLOW
Suffix:
Gender:M
Credentials:OD
Other - Prefix:
Other - First Name:
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Mailing Address - Street 1:407 S GREENWOOD ST
Mailing Address - Street 2:
Mailing Address - City:LAGRANGE
Mailing Address - State:GA
Mailing Address - Zip Code:30240-3123
Mailing Address - Country:US
Mailing Address - Phone:706-882-0616
Mailing Address - Fax:706-882-8515
Practice Address - Street 1:407 S GREENWOOD ST
Practice Address - Street 2:
Practice Address - City:LAGRANGE
Practice Address - State:GA
Practice Address - Zip Code:30240-3123
Practice Address - Country:US
Practice Address - Phone:706-882-0616
Practice Address - Fax:706-882-8515
Is Sole Proprietor?:No
Enumeration Date:2005-09-19
Last Update Date:2010-07-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GAOPT001301152W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes152W00000XEye and Vision Services ProvidersOptometrist
Provider Identifiers
StateIdentifier IDID TypeIssuer
GA000546125AMedicaid
GA5243394001OtherBLUE CROSS BLUE SHIELD
GA0522840001OtherDMERC
GA410024976OtherMEDICARE RAILROAD RETIREM
GA5243394001OtherBLUE CROSS BLUE SHIELD
GAU27747Medicare UPIN