Provider Demographics
NPI:1912903162
Name:WHITNEY, OLIVER WENDELL (OD)
Entity Type:Individual
Prefix:DR
First Name:OLIVER
Middle Name:WENDELL
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:PO BOX 879
Mailing Address - Street 2:
Mailing Address - City:MANDEVILLE
Mailing Address - State:LA
Mailing Address - Zip Code:70470-0879
Mailing Address - Country:US
Mailing Address - Phone:985-626-5242
Mailing Address - Fax:
Practice Address - Street 1:1580 W CAUSEWAY APPROACH
Practice Address - Street 2:STE 3
Practice Address - City:MANDEVILLE
Practice Address - State:LA
Practice Address - Zip Code:70471-3033
Practice Address - Country:US
Practice Address - Phone:985-626-5242
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2005-06-22
Last Update Date:2010-12-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
LA810300T152W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes152W00000XEye and Vision Services ProvidersOptometrist
Provider Identifiers
StateIdentifier IDID TypeIssuer
LA1176923Medicaid
47832Medicare ID - Type Unspecified
LA1176923Medicaid