Healthcare Provider Details

I. General information

NPI: 1699707638
Provider Name (Legal Business Name): JOHN R WHITWORTH M.D.
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 07/07/2006
Last Update Date: 07/09/2007
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

806 ESTATE PL
MEMPHIS TN
38120-0600
US

IV. Provider business mailing address

2670 UNION AVENUE EXT SUITE 1220
MEMPHIS TN
38112-4426
US

V. Phone/Fax

Practice location:
  • Phone: 901-681-4017
  • Fax: 901-681-4013
Mailing address:
  • Phone: 901-458-9785
  • Fax: 901-458-8192

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code2080P0206X
TaxonomyPediatric Gastroenterology Physician
License Number34143
License Number StateTN

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: