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NPI Code Detail

MEDICARE: DR. JOHNATHAN JACK WHITAKER D.O.

MEDICARE: DR. JOHNATHAN JACK WHITAKER D.O.
Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

# Taxonomy Code Taxonomy License Number License Number State
1207X00000XOrthopaedic Surgery PhysicianOT013666PA
2207X00000XOrthopaedic Surgery Physician2806TN
3207X00000XOrthopaedic Surgery PhysicianOS017457PA
4207X00000XOrthopaedic Surgery Physician2015-00253NC

General Provider Information

NPI Number : 1376863456
Entity Type Code : Individual
Provider Name (Legal Business Name) : DR. JOHNATHAN JACK WHITAKER D.O.
Provider Business Mailing Address
First Line : 400 JOHNSON RIDGE MEDICAL PARK
Second Line :
City : ELKIN
State : NC
Zip : 28621-2447
Country : US
Telephone Number :
Fax Number :
Provider Business Practice Location Address
First Line : 400 JOHNSON RIDGE MEDICAL PARK
Second Line :
City : ELKIN
State : NC
Zip : 28621-2447
Country : US
Telephone Number : 336-526-4500
Fax Number :
Authorized Official
Title or Position :
Name :
Credential :
Telephone Number :
Provider Enumeration Date : 06/11/2010
Last Update Date : 07/08/2015

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