Provider Demographics
NPI:1447299581
Name:WHITAKER, WILLIAM LEE (OD)
Entity type:Individual
Prefix:DR
First Name:WILLIAM
Middle Name:LEE
Last Name:WHITAKER
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 1:1950 OLD GALLOWS RD STE 520
Mailing Address - Street 2:
Mailing Address - City:VIENNA
Mailing Address - State:VA
Mailing Address - Zip Code:22182-3970
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:2032 VETERANS BLVD STE A
Practice Address - Street 2:
Practice Address - City:DUBLIN
Practice Address - State:GA
Practice Address - Zip Code:31021-3065
Practice Address - Country:US
Practice Address - Phone:478-272-3445
Practice Address - Fax:478-272-4802
Is Sole Proprietor?:No
Enumeration Date:2006-06-05
Last Update Date:2022-04-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GAOPT000975152W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes152W00000XEye and Vision Services ProvidersOptometrist
Provider Identifiers
StateIdentifier IDID TypeIssuer
GA000230271AMedicaid
GA55490154SAMedicare ID - Type Unspecified
GA000230271AMedicaid