Healthcare Provider Details

I. General information

NPI: 1033104344
Provider Name (Legal Business Name): EDWARD W WHITESIDES M.D.
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 09/13/2005
Last Update Date: 12/05/2023
Certification Date: 12/05/2023
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1905 GLEN MEADE RD
WILMINGTON NC
28403-6024
US

IV. Provider business mailing address

1905 GLEN MEADE RD
WILMINGTON NC
28403-6024
US

V. Phone/Fax

Practice location:
  • Phone: 910-763-6251
  • Fax: 910-763-7408
Mailing address:
  • Phone: 910-763-6251
  • Fax: 910-763-7408

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code174400000X
TaxonomySpecialist
License Number36671
License Number StateNC
# 2
Primary TaxonomyN
Taxonomy Code208800000X
TaxonomyUrology Physician
License NumberD98830
License Number StateMD

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: