Provider Demographics
NPI:1750717336
Name:WHITESELL, RASIKA KHATU (OD)
Entity type:Individual
Prefix:DR
First Name:RASIKA
Middle Name:KHATU
Last Name:WHITESELL
Suffix:
Gender:F
Credentials:OD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
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Other - Credentials:
Mailing Address - Street 1:1345 WESTERN BLVD
Mailing Address - Street 2:STE 120B
Mailing Address - City:JACKSONVILLE
Mailing Address - State:NC
Mailing Address - Zip Code:28546-7627
Mailing Address - Country:US
Mailing Address - Phone:910-376-8229
Mailing Address - Fax:
Practice Address - Street 1:3501 OLEANDER DR STE 7
Practice Address - Street 2:
Practice Address - City:WILMINGTON
Practice Address - State:NC
Practice Address - Zip Code:28403-0824
Practice Address - Country:US
Practice Address - Phone:910-254-9292
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2013-09-16
Last Update Date:2020-10-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NC2354152W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes152W00000XEye and Vision Services ProvidersOptometrist
Provider Identifiers
StateIdentifier IDID TypeIssuer
NCNCF057C699Medicare PIN