1194734467 NPI number — DR. MARY CANDACE WHITEHURST MD

Table of content: DR. MARY CANDACE WHITEHURST MD (NPI 1194734467)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1194734467 NPI number — DR. MARY CANDACE WHITEHURST MD

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
Provider Last Name:
WHITEHURST
Provider First Name:
MARY
Provider Middle Name:
CANDACE
Provider Name Prefix Text:
DR.
Provider Name Suffix Text:
Provider Credential Text:
MD
Provider Gender Code:
F

Provider's Other Name Information

Provider Other Organization Name:
Provider Other Organization Name Type Code:
Provider Other Last Name:
Provider Other First Name:
Provider Other Middle Name:
Provider Other Name Prefix Text:
Provider Other Name Suffix Text:
Provider Other Credential Text:
Provider Other Last Name Type Code:

NPI Number Information

NPI Number:
1194734467
Entity Type Code:
Individual
Replacement NPI:
Last Update Date:
05/25/2016
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
7007 HARBOUR VIEW BLVD
Provider Second Line Business Mailing Address:
SUITE 108
Provider Business Mailing Address City Name:
SUFFOLK
Provider Business Mailing Address State Name:
VA
Provider Business Mailing Address Postal Code:
23435-3657
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
757-215-2784
Provider Business Mailing Address Fax Number:
757-215-2728

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
930 W 21ST ST
Provider Second Line Business Practice Location Address:
SUITE 100
Provider Business Practice Location Address City Name:
NORFOLK
Provider Business Practice Location Address State Name:
VA
Provider Business Practice Location Address Postal Code:
23517-1516
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
757-622-8358
Provider Business Practice Location Address Fax Number:
757-622-7171
Provider Enumeration Date:
08/05/2006

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: 207R00000X , with the licence number:  0101041536 , registered in the state of VA ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

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

  • Identifier: 5824826 , issued by the state of ( VA ) . This identifiers is of the category "MEDICAID".
  • Identifier: 13900 . This is a "OPTIMA HEALTH PLAN" identifier , issued by the state of ( VA ) . This identifiers is of the category "OTHER".
  • Identifier: 325493 . This is a "ANTHEM BLUE CROSS BLUE SH" identifier , issued by the state of ( VA ) . This identifiers is of the category "OTHER".
  • Identifier: 011268 . This is a "CIGNA HEALTH PLAN" identifier , issued by the state of ( VA ) . This identifiers is of the category "OTHER".
  • Identifier: 1100181707 . This is a "RAILROAD MEDICARE" identifier , issued by the state of ( VA ) . This identifiers is of the category "OTHER".




Copyright © 2007-2025 www.npivalidator.com