Provider Demographics
NPI:1366925620
Name:WHITTINGTON, MARK JEFFERY (OD)
Entity type:Individual
Prefix:MR
First Name:MARK
Middle Name:JEFFERY
Last Name:WHITTINGTON
Suffix:
Gender:M
Credentials:OD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
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Other - Credentials:
Mailing Address - Street 1:3840 PENNSYLVANIA AVE
Mailing Address - Street 2:
Mailing Address - City:CHARLESTON
Mailing Address - State:WV
Mailing Address - Zip Code:25302-4650
Mailing Address - Country:US
Mailing Address - Phone:304-342-0660
Mailing Address - Fax:304-344-5483
Practice Address - Street 1:3840 PENNSYLVANIA AVE
Practice Address - Street 2:
Practice Address - City:CHARLESTON
Practice Address - State:WV
Practice Address - Zip Code:25302-4650
Practice Address - Country:US
Practice Address - Phone:304-342-0660
Practice Address - Fax:304-344-5483
Is Sole Proprietor?:No
Enumeration Date:2018-09-12
Last Update Date:2018-09-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WV2052-IOD152W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes152W00000XEye and Vision Services ProvidersOptometrist