Healthcare Provider Details

I. General information

NPI: 1447245931
Provider Name (Legal Business Name): JAMES D. WHITWORTH PH.D.
Entity Type: Individual
Gender: Male
Sole Proprietor: X

II. Dates (important events)

Enumeration Date: 09/12/2005
Last Update Date: 07/08/2007
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

307 BOATNER RD STE 114, FAMILY MEDICINE RESIDENCY
EGLIN AFB FL
32542-1391
US

IV. Provider business mailing address

307 BOATNER RD STE 114, FAMILY MEDICINE RESIDENCY
EGLIN AFB FL
32542-1391
US

V. Phone/Fax

Practice location:
  • Phone: 850-883-8173
  • Fax: 850-883-2468
Mailing address:
  • Phone: 850-883-8173
  • Fax: 850-883-2468

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code1041C0700X
TaxonomyClinical Social Worker
License NumberSW4555
License Number StateFL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: