Healthcare Provider Details

I. General information

NPI: 1063404002
Provider Name (Legal Business Name): THOMAS L WHITTAKER MD
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 08/16/2005
Last Update Date: 08/10/2012
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

ONE MEMORIAL SQ STE 50
GREENFIELD IN
46140-1357
US

IV. Provider business mailing address

6330 E 75TH ST
INDIANAPOLIS IN
46250-2777
US

V. Phone/Fax

Practice location:
  • Phone: 317-467-7100
  • Fax: 317-467-0209
Mailing address:
  • Phone: 317-594-6900
  • Fax: 317-594-6911

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207RX0202X
TaxonomyMedical Oncology Physician
License Number01041624
License Number StateIN
# 2
Primary TaxonomyN
Taxonomy Code207RH0000X
TaxonomyHematology (Internal Medicine) Physician
License Number01041624
License Number StateIN

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: