Basic Information
| Provider Information | |||||||||
| NPI: | 1285666487 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | WHITTON | ||||||||
| FirstName: | GERALD | ||||||||
| MiddleName: | BRENT | ||||||||
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| Credential: | MD | ||||||||
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| Mailing Information | |||||||||
| Address1: | PO BOX 3038 | ||||||||
| Address2: | |||||||||
| City: | SHREVEPORT | ||||||||
| State: | LA | ||||||||
| PostalCode: | 711333038 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 3182125970 | ||||||||
| FaxNumber: | 3182125975 | ||||||||
| Practice Location | |||||||||
| Address1: | 2510 BERT KOUNS INDUSTRIAL LOOP STE 215 | ||||||||
| Address2: | |||||||||
| City: | SHREVEPORT | ||||||||
| State: | LA | ||||||||
| PostalCode: | 711183119 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 3182125970 | ||||||||
| FaxNumber: | 3182125975 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 07/07/2006 | ||||||||
| LastUpdateDate: | 06/17/2021 | ||||||||
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| ProviderGenderCode: | M | ||||||||
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| IsSoleProprietor: | N | ||||||||
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| NPICertificationDate: | 06/17/2021 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 2080N0001X | 024459 | LA | Y | Allopathic & Osteopathic Physicians | Pediatrics | Neonatal-Perinatal Medicine |
ID Information
| ID | Type | State | Issuer | Description | 1572179 | 05 | LA | MEDICAID |