Healthcare Provider Details

I. General information

NPI: 1487630919
Provider Name (Legal Business Name): RICHARD JAMES WHITEHEAD JR. PAC
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 12/16/2005
Last Update Date: 03/25/2015
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

410 SAYBROOK RD SUITE 201
MIDDLETOWN CT
06457-4777
US

IV. Provider business mailing address

410 SAYBROOK RD SUITE 201
MIDDLETOWN CT
06457
US

V. Phone/Fax

Practice location:
  • Phone: 860-347-4620
  • Fax: 860-344-5995
Mailing address:
  • Phone: 860-347-4620
  • Fax: 860-346-9687

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code363AM0700X
TaxonomyMedical Physician Assistant
License Number000881
License Number StateCT
# 2
Primary TaxonomyY
Taxonomy Code363A00000X
TaxonomyPhysician Assistant
License Number0000881
License Number StateCT

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: