Basic Information
| Provider Information | |||||||||
| NPI: | 1427089663 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | WHITAKER | ||||||||
| FirstName: | DAVID | ||||||||
| MiddleName: | ELLIS | ||||||||
| NamePrefix: | DR. | ||||||||
| NameSuffix: | |||||||||
| Credential: | D.O. | ||||||||
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| Mailing Information | |||||||||
| Address1: | PO BOX 3002 | ||||||||
| Address2: | |||||||||
| City: | LONGVIEW | ||||||||
| State: | WA | ||||||||
| PostalCode: | 986320302 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 3605013601 | ||||||||
| FaxNumber: | 3605013648 | ||||||||
| Practice Location | |||||||||
| Address1: | 1615 DELAWARE ST | ||||||||
| Address2: | |||||||||
| City: | LONGVIEW | ||||||||
| State: | WA | ||||||||
| PostalCode: | 986322367 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 3605013601 | ||||||||
| FaxNumber: | 3605013648 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 07/05/2006 | ||||||||
| LastUpdateDate: | 07/30/2012 | ||||||||
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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 | 207Q00000X | OP60061604 | WA | Y | Allopathic & Osteopathic Physicians | Family Medicine |
ID Information
| ID | Type | State | Issuer | Description | 00AX58090 | 05 | CA | MEDICAID | 500603460 | 05 | OR | MEDICAID | 8534620 | 05 | WA | MEDICAID |