Healthcare Provider Details

I. General information

NPI: 1063489326
Provider Name (Legal Business Name): JOHN M WILHITE M.D.
Entity Type: Individual
Gender: Male
Sole Proprietor: X

II. Dates (important events)

Enumeration Date: 03/07/2006
Last Update Date: 07/08/2007
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1650 COCHRANE CIR
FT CARSON CO
80913-4603
US

IV. Provider business mailing address

6923 BITTERROOT DR
COLORADO SPRINGS CO
80918-7327
US

V. Phone/Fax

Practice location:
  • Phone: 719-524-4051
  • Fax: 719-526-7272
Mailing address:
  • Phone: 719-526-7600
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207QS0010X
TaxonomySports Medicine (Family Medicine) Physician
License Number36923
License Number StateCO

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: