Provider Demographics
NPI:1962436923
Name:WAITE, GEORGE W (OD)
Entity type:Individual
Prefix:
First Name:GEORGE
Middle Name:W
Last Name:WAITE
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 1:12 CROSSWAY CT E
Mailing Address - Street 2:
Mailing Address - City:PALM COAST
Mailing Address - State:FL
Mailing Address - Zip Code:32137-8903
Mailing Address - Country:US
Mailing Address - Phone:386-864-7378
Mailing Address - Fax:386-864-7378
Practice Address - Street 1:12 CROSSWAY CT E
Practice Address - Street 2:
Practice Address - City:PALM COAST
Practice Address - State:FL
Practice Address - Zip Code:32137-8903
Practice Address - Country:US
Practice Address - Phone:386-864-7378
Practice Address - Fax:386-864-7378
Is Sole Proprietor?:Yes
Enumeration Date:2006-07-10
Last Update Date:2008-12-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLOPC001255152W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes152W00000XEye and Vision Services ProvidersOptometrist
Provider Identifiers
StateIdentifier IDID TypeIssuer
FL078813900Medicaid
FL19481Medicare ID - Type Unspecified
FL078813900Medicaid