Basic Information
| Provider Information | |||||||||
| NPI: | 1184914491 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | WHIDDON | ||||||||
| FirstName: | RICHARD | ||||||||
| MiddleName: | EHREN | ||||||||
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| Credential: | D.O. | ||||||||
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| Mailing Information | |||||||||
| Address1: | PO BOX 841656 | ||||||||
| Address2: | |||||||||
| City: | DALLAS | ||||||||
| State: | TX | ||||||||
| PostalCode: | 752841656 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 9035315000 | ||||||||
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| Practice Location | |||||||||
| Address1: | 800 E DAWSON ST | ||||||||
| Address2: | |||||||||
| City: | TYLER | ||||||||
| State: | TX | ||||||||
| PostalCode: | 757012036 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 9035315286 | ||||||||
| FaxNumber: | 9035315061 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 04/08/2011 | ||||||||
| LastUpdateDate: | 12/02/2015 | ||||||||
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| ProviderGenderCode: | M | ||||||||
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| IsSoleProprietor: | N | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 207P00000X | P9135 | TX | Y | Allopathic & Osteopathic Physicians | Emergency Medicine |
ID Information
| ID | Type | State | Issuer | Description | 350234603 | 05 | TX | MEDICAID | 350234602 | 05 | TX | MEDICAID | 350234601 | 05 | TX | MEDICAID | 350234604 | 05 | TX | MEDICAID |