Provider Demographics
NPI:1730189382
Name:WHALEY, SUSAN S (OD)
Entity type:Individual
Prefix:DR
First Name:SUSAN
Middle Name:S
Last Name:WHALEY
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 1:2858 MAHAN DR
Mailing Address - Street 2:SUITE 4
Mailing Address - City:TALLAHASSEE
Mailing Address - State:FL
Mailing Address - Zip Code:32308-5446
Mailing Address - Country:US
Mailing Address - Phone:850-671-3936
Mailing Address - Fax:850-671-3239
Practice Address - Street 1:2858 MAHAN DR
Practice Address - Street 2:SUITE 4
Practice Address - City:TALLAHASSEE
Practice Address - State:FL
Practice Address - Zip Code:32308-5446
Practice Address - Country:US
Practice Address - Phone:850-671-3936
Practice Address - Fax:850-671-3239
Is Sole Proprietor?:Yes
Enumeration Date:2005-07-26
Last Update Date:2017-06-05
Deactivation Date:2006-03-21
Deactivation Code:
Reactivation Date:2006-03-29
Provider Licenses
StateLicense IDTaxonomies
FLOPC2689152W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes152W00000XEye and Vision Services ProvidersOptometrist
Provider Identifiers
StateIdentifier IDID TypeIssuer
FL20465OtherBLUE CROSS BLUE SHIELD
FLU47000Medicare UPIN
FL20465XMedicare ID - Type Unspecified