Basic Information
| Provider Information | |||||||||
| NPI: | 1861460487 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | WHITMAN | ||||||||
| FirstName: | CHERYL | ||||||||
| MiddleName: | JEAN | ||||||||
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| Credential: | MD | ||||||||
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| Mailing Information | |||||||||
| Address1: | 2025 GALISTEO ST | ||||||||
| Address2: | |||||||||
| City: | SANTA FE | ||||||||
| State: | NM | ||||||||
| PostalCode: | 875052101 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 5059954901 | ||||||||
| FaxNumber: | 5059896426 | ||||||||
| Practice Location | |||||||||
| Address1: | 2025 GALISTEO ST | ||||||||
| Address2: | |||||||||
| City: | SANTA FE | ||||||||
| State: | NM | ||||||||
| PostalCode: | 875052101 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 5059954901 | ||||||||
| FaxNumber: | 5059896426 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 03/09/2006 | ||||||||
| LastUpdateDate: | 11/08/2011 | ||||||||
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| ProviderGenderCode: | F | ||||||||
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| IsSoleProprietor: | N | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 208000000X | 76-288 | NM | Y | Allopathic & Osteopathic Physicians | Pediatrics |
ID Information
| ID | Type | State | Issuer | Description | PROVP16692 | 01 | MOLINA HEALTHCARE | OTHER | 201010702 | 01 | PRESBYTERIAN HEALTH PLAN | OTHER | 29421 | 05 | NM | MEDICAID | 31071 | 01 | LOVELACE | OTHER | 1699563 | 01 | UHC | OTHER | NM003054 | 01 | NM | BCBS NM | OTHER |