Basic Information
| Provider Information | |||||||||
| NPI: | 1265431860 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | WHITEHEAD | ||||||||
| FirstName: | JOHN | ||||||||
| MiddleName: | R | ||||||||
| NamePrefix: | DR. | ||||||||
| NameSuffix: | |||||||||
| Credential: | D.O. | ||||||||
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| Mailing Information | |||||||||
| Address1: | 2610 N WOODLAWN BLVD | ||||||||
| Address2: | |||||||||
| City: | WICHITA | ||||||||
| State: | KS | ||||||||
| PostalCode: | 672202729 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 3168582610 | ||||||||
| FaxNumber: | 3168582793 | ||||||||
| Practice Location | |||||||||
| Address1: | 2610 N WOODLAWN BLVD | ||||||||
| Address2: | |||||||||
| City: | WICHITA | ||||||||
| State: | KS | ||||||||
| PostalCode: | 672202729 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 3168582610 | ||||||||
| FaxNumber: | 3168582793 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 07/18/2005 | ||||||||
| LastUpdateDate: | 12/17/2010 | ||||||||
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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 | 05-20530 | KS | Y | Allopathic & Osteopathic Physicians | Emergency Medicine | 207Q00000X | 05-20530 | KS | N | Allopathic & Osteopathic Physicians | Family Medicine |
ID Information
| ID | Type | State | Issuer | Description | P00615209 | 01 | KS | RR MEDICARE (PALMETTO) | OTHER | 100229810I | 05 | KS | MEDICAID | 100229810J | 05 | KS | MEDICAID | 100229810R | 05 | KS | MEDICAID | 100229810Q | 05 | KS | MEDICAID |