Healthcare Provider Details

I. General information

NPI: 1477493666
Provider Name (Legal Business Name): WILLIAM WHITESIDE MD STUDENT
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 03/30/2026
Last Update Date: 03/30/2026
Certification Date: 03/30/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

500 J CLYDE MORRIS BLVD
NEWPORT NEWS VA
23601-1929
US

IV. Provider business mailing address

3708 ELLWOOD AVE
RICHMOND VA
23221-2612
US

V. Phone/Fax

Practice location:
  • Phone: 757-594-3945
  • Fax:
Mailing address:
  • Phone: 540-246-2134
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code390200000X
TaxonomyStudent in an Organized Health Care Education/Training Program
License Number
License Number StateVA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: