Healthcare Provider Details

I. General information

NPI: 1700863388
Provider Name (Legal Business Name): ROBERT D WHITEHEAD M.D.
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 12/27/2005
Last Update Date: 03/07/2017
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

5040 FOREST DR SUITE 300
NEW ALBANY OH
43054-8181
US

IV. Provider business mailing address

70 S CLEVELAND AVE
WESTERVILLE OH
43081-1397
US

V. Phone/Fax

Practice location:
  • Phone: 614-890-6555
  • Fax: 614-775-1484
Mailing address:
  • Phone: 614-839-3275
  • Fax: 614-775-1484

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207QS0010X
TaxonomySports Medicine (Family Medicine) Physician
License Number35-062312
License Number StateOH

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: