Healthcare Provider Details

I. General information

NPI: 1164602926
Provider Name (Legal Business Name): JUSTIN T WHISENANT MD
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 11/09/2007
Last Update Date: 07/03/2025
Certification Date: 07/03/2025
Deactivation Date:
Reactivation Date:

III. Provider practice location address

6500 38TH AVE N
ST PETERSBURG FL
33710-1629
US

IV. Provider business mailing address

909 FROSTWOOD DR STE 1.100
HOUSTON TX
77024-2301
US

V. Phone/Fax

Practice location:
  • Phone: 727-384-1414
  • Fax: 727-345-8075
Mailing address:
  • Phone: 713-338-5519
  • Fax: 713-704-3086

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code2085N0700X
TaxonomyNeuroradiology Physician
License Number2011015524
License Number StateMO
# 2
Primary TaxonomyN
Taxonomy Code2085N0700X
TaxonomyNeuroradiology Physician
License NumberN4199
License Number StateTX
# 3
Primary TaxonomyN
Taxonomy Code2085N0700X
TaxonomyNeuroradiology Physician
License NumberMD2022-1392
License Number StateNM
# 4
Primary TaxonomyN
Taxonomy Code2085N0700X
TaxonomyNeuroradiology Physician
License NumberME128898
License Number StateFL
# 5
Primary TaxonomyN
Taxonomy Code2085R0204X
TaxonomyVascular & Interventional Radiology Physician
License NumberME128898
License Number StateFL
# 6
Primary TaxonomyN
Taxonomy Code390200000X
TaxonomyStudent in an Organized Health Care Education/Training Program
License Number
License Number State
# 7
Primary TaxonomyY
Taxonomy Code2085R0202X
TaxonomyDiagnostic Radiology Physician
License NumberFW1856371
License Number StateCO

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: