Provider Demographics
NPI:1386907152
Name:WHITELY, KIMBERLY ANN (OD)
Entity type:Individual
Prefix:
First Name:KIMBERLY
Middle Name:ANN
Last Name:WHITELY
Suffix:
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 1:2155 84TH ST SW
Mailing Address - Street 2:
Mailing Address - City:BYRON CENTER
Mailing Address - State:MI
Mailing Address - Zip Code:49315-8260
Mailing Address - Country:US
Mailing Address - Phone:616-878-3600
Mailing Address - Fax:616-878-7098
Practice Address - Street 1:2155 84TH ST SW
Practice Address - Street 2:
Practice Address - City:BYRON CENTER
Practice Address - State:MI
Practice Address - Zip Code:49315-8260
Practice Address - Country:US
Practice Address - Phone:616-878-3600
Practice Address - Fax:616-878-7098
Is Sole Proprietor?:No
Enumeration Date:2012-06-18
Last Update Date:2015-11-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI4901004711152W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes152W00000XEye and Vision Services ProvidersOptometrist
Provider Identifiers
StateIdentifier IDID TypeIssuer
MI0C97655Medicare PIN