Healthcare Provider Details

I. General information

NPI: 1427089663
Provider Name (Legal Business Name): DAVID ELLIS WHITAKER D.O.
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 07/05/2006
Last Update Date: 07/30/2012
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1615 DELAWARE ST
LONGVIEW WA
98632-2367
US

IV. Provider business mailing address

PO BOX 3002
LONGVIEW WA
98632-0302
US

V. Phone/Fax

Practice location:
  • Phone: 360-501-3601
  • Fax: 360-501-3648
Mailing address:
  • Phone: 360-501-3601
  • Fax: 360-501-3648

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207Q00000X
TaxonomyFamily Medicine Physician
License NumberOP60061604
License Number StateWA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: