Provider Demographics
NPI:1992927891
Name:WHITTINGTON, CRYSTAL G (OD)
Entity type:Individual
Prefix:
First Name:CRYSTAL
Middle Name:G
Last Name:WHITTINGTON
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 1:2861 TRICOM ST
Mailing Address - Street 2:
Mailing Address - City:NORTH CHARLESTON
Mailing Address - State:SC
Mailing Address - Zip Code:29406-9172
Mailing Address - Country:US
Mailing Address - Phone:843-725-0064
Mailing Address - Fax:843-569-7885
Practice Address - Street 1:296 MIDLAND PARKWAY
Practice Address - Street 2:
Practice Address - City:SUMMERVILLE
Practice Address - State:SC
Practice Address - Zip Code:29485
Practice Address - Country:US
Practice Address - Phone:843-873-5577
Practice Address - Fax:843-873-5583
Is Sole Proprietor?:No
Enumeration Date:2007-05-02
Last Update Date:2022-03-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
SC1275152W00000X, 152WC0802X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes152W00000XEye and Vision Services ProvidersOptometrist
No152WC0802XEye and Vision Services ProvidersOptometristCorneal and Contact Management
Provider Identifiers
StateIdentifier IDID TypeIssuer
SCD12751Medicaid
5911Medicare PIN
SCV03937Medicare UPIN
SCD12751Medicaid
SC5910Medicare PIN
SC0368630003Medicare NSC
SC5912Medicare PIN
SCAA07792326Medicare PIN
SC5909Medicare PIN
SCD12751Medicaid