Provider Demographics
NPI:1982615977
Name:WHITTAKER, TERI K I (OD)
Entity Type:Individual
Prefix:
First Name:TERI
Middle Name:K
Last Name:WHITTAKER
Suffix:I
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 1:11225 HURON LN STE 200A
Mailing Address - Street 2:
Mailing Address - City:LITTLE ROCK
Mailing Address - State:AR
Mailing Address - Zip Code:72211-1861
Mailing Address - Country:US
Mailing Address - Phone:501-653-2020
Mailing Address - Fax:501-653-7407
Practice Address - Street 1:2900 HORIZON DR STE 15
Practice Address - Street 2:
Practice Address - City:BRYANT
Practice Address - State:AR
Practice Address - Zip Code:72022-9095
Practice Address - Country:US
Practice Address - Phone:504-653-2020
Practice Address - Fax:501-653-7407
Is Sole Proprietor?:No
Enumeration Date:2006-08-11
Last Update Date:2020-06-25
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AR2573152W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes152W00000XEye and Vision Services ProvidersOptometrist
Provider Identifiers
StateIdentifier IDID TypeIssuer
AR163095722Medicaid