Basic Information
| Provider Information | |||||||||
| NPI: | 1679556427 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | WHITESIDE | ||||||||
| FirstName: | JOHN | ||||||||
| MiddleName: | W | ||||||||
| NamePrefix: | DR. | ||||||||
| NameSuffix: | II | ||||||||
| Credential: | M.D. | ||||||||
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| Mailing Information | |||||||||
| Address1: | 2333 N 6TH ST | ||||||||
| Address2: | |||||||||
| City: | GRAND JUNCTION | ||||||||
| State: | CO | ||||||||
| PostalCode: | 815012001 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 9702981782 | ||||||||
| FaxNumber: | 9702981726 | ||||||||
| Practice Location | |||||||||
| Address1: | 833 CHESTNUT ST STE 301 | ||||||||
| Address2: | |||||||||
| City: | PHILADELPHIA | ||||||||
| State: | PA | ||||||||
| PostalCode: | 191074405 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 2159557190 | ||||||||
| FaxNumber: | 2159558600 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 11/25/2005 | ||||||||
| LastUpdateDate: | 02/05/2019 | ||||||||
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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 | 47640 | CO | N | Allopathic & Osteopathic Physicians | Family Medicine | 207Q00000X | MD466263 | PA | Y | Allopathic & Osteopathic Physicians | Family Medicine |
ID Information
| ID | Type | State | Issuer | Description | 840425720-308 | 01 | CO | HMO# | OTHER | 47008849 | 05 | CO | MEDICAID |