Provider Demographics
NPI:1962605105
Name:SUSAN C WHITAKER OD PA
Entity type:Organization
Organization Name:SUSAN C WHITAKER OD PA
Other - Org Name:<UNAVAIL>
Other - Org Type:
Authorized Official - Title/Position:OPTOMETIST
Authorized Official - Prefix:
Authorized Official - First Name:SUSAN
Authorized Official - Middle Name:C
Authorized Official - Last Name:BAILEY
Authorized Official - Suffix:
Authorized Official - Credentials:OD
Authorized Official - Phone:910-947-7740
Mailing Address - Street 1:PO BOX 875
Mailing Address - Street 2:
Mailing Address - City:CARTHAGE
Mailing Address - State:NC
Mailing Address - Zip Code:28327-0875
Mailing Address - Country:US
Mailing Address - Phone:910-947-7740
Mailing Address - Fax:910-947-7742
Practice Address - Street 1:101 MONROE PL
Practice Address - Street 2:
Practice Address - City:CARTHAGE
Practice Address - State:NC
Practice Address - Zip Code:28327-9784
Practice Address - Country:US
Practice Address - Phone:910-947-7740
Practice Address - Fax:910-947-7742
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-06-06
Last Update Date:2008-04-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NCNC1253152W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes152W00000XEye and Vision Services ProvidersOptometristGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
NC890252XMedicaid
NC2470096Medicare ID - Type Unspecified
NC890252XMedicaid
NC0738460001Medicare NSC