1588192009 NPI number — DR. COURTNEY LANAE WHITEHURST DO

Table of content: DR. COURTNEY LANAE WHITEHURST DO (NPI 1588192009)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1588192009 NPI number — DR. COURTNEY LANAE WHITEHURST DO

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
Provider Last Name:
WHITEHURST
Provider First Name:
COURTNEY
Provider Middle Name:
LANAE
Provider Name Prefix Text:
DR.
Provider Name Suffix Text:
Provider Credential Text:
DO
Provider Gender Code:
F

Provider's Other Name Information

Provider Other Organization Name:
Provider Other Organization Name Type Code:
Provider Other Last Name:
NORMAN
Provider Other First Name:
COURTNEY
Provider Other Middle Name:
LANAE
Provider Other Name Prefix Text:
Provider Other Name Suffix Text:
Provider Other Credential Text:
DO
Provider Other Last Name Type Code:
1

NPI Number Information

NPI Number:
1588192009
Entity Type Code:
Individual
Replacement NPI:
Last Update Date:
01/13/2025
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
PO BOX 846098
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
DALLAS
Provider Business Mailing Address State Name:
TX
Provider Business Mailing Address Postal Code:
75284-6098
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
903-606-6400
Provider Business Mailing Address Fax Number:
903-606-1522

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
2401 S 31ST ST
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
TEMPLE
Provider Business Practice Location Address State Name:
TX
Provider Business Practice Location Address Postal Code:
76508-0001
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
254-724-2111
Provider Business Practice Location Address Fax Number:
Provider Enumeration Date:
05/28/2017

Additional Information

Authorized Official

Authorized Official Last Name:
Authorized Official First Name:
Authorized Official Middle Name:
Authorized Official Title or Position:
Authorized Official Telephone Number:

Provider Taxonomy Codes

  • Taxonomy code: 208M00000X , with the licence number:  S5103 , registered in the state of TX ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

Other Provider's Identifiers (legacy, non-NPI)





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