Basic Information
| Provider Information | |||||||||
| NPI: | 1972539302 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | WHITLOCK-MORALES | ||||||||
| FirstName: | AUTUMN | ||||||||
| MiddleName: | BETH | ||||||||
| NamePrefix: | DR. | ||||||||
| NameSuffix: | |||||||||
| Credential: | MD | ||||||||
| OtherOrganizationName: | |||||||||
| OtherOrganizationType: | |||||||||
| OtherLastName: | WHITLOCK-MORALES | ||||||||
| OtherFirstName: | AUTUMN | ||||||||
| OtherMiddleName: | BETH | ||||||||
| OtherNamePrefix: | |||||||||
| OtherNameSuffix: | |||||||||
| OtherCredential: | MD | ||||||||
| OtherLastNameType: | 2 | ||||||||
| Mailing Information | |||||||||
| Address1: | 2900 SAINT MICHAEL DR STE 401 | ||||||||
| Address2: | |||||||||
| City: | TEXARKANA | ||||||||
| State: | TX | ||||||||
| PostalCode: | 755035211 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 9036145372 | ||||||||
| FaxNumber: | 9036145343 | ||||||||
| Practice Location | |||||||||
| Address1: | 1311 E GENERAL CAVAZOS BLVD STE 201 | ||||||||
| Address2: | |||||||||
| City: | KINGSVILLE | ||||||||
| State: | TX | ||||||||
| PostalCode: | 783637123 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 3615952223 | ||||||||
| FaxNumber: | 3615959687 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 06/25/2006 | ||||||||
| LastUpdateDate: | 04/20/2021 | ||||||||
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| ProviderGenderCode: | F | ||||||||
| AuthorizedOfficialLastName: | |||||||||
| AuthorizedOfficialFirstName: | |||||||||
| AuthorizedOfficialMiddleName: | |||||||||
| AuthorizedOfficialTitleorPosition: | |||||||||
| AuthorizedOfficialTelephone: | |||||||||
| IsSoleProprietor: | N | ||||||||
| IsOrganizationSubpart: | |||||||||
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| AuthorizedOfficialNamePrefix: | |||||||||
| AuthorizedOfficialNameSuffix: | |||||||||
| AuthorizedOfficialCredential: | |||||||||
| NPICertificationDate: | 04/20/2021 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 207R00000X | 22119 | WV | N | Allopathic & Osteopathic Physicians | Internal Medicine | 207R00000X | 39466 | IA | N | Allopathic & Osteopathic Physicians | Internal Medicine | 208000000X | 39466 | IA | N | Allopathic & Osteopathic Physicians | Pediatrics | 208000000X | R9558 | TX | Y | Allopathic & Osteopathic Physicians | Pediatrics |
ID Information
| ID | Type | State | Issuer | Description | PENDING | 05 | TX | MEDICAID | 3810005860 | 05 | WV | MEDICAID |