Healthcare Provider Details

I. General information

NPI: 1073550323
Provider Name (Legal Business Name): TROY R WITHERRITE M.D.
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 06/02/2006
Last Update Date: 07/29/2008
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

212 SKYLINE DR
WHITE SALMON WA
98672-0212
US

IV. Provider business mailing address

212 SKYLINE DR BOX 1519
WHITE SALMON WA
98672-1519
US

V. Phone/Fax

Practice location:
  • Phone: 509-493-2133
  • Fax: 509-493-9538
Mailing address:
  • Phone: 509-493-9533
  • Fax: 509-493-9538

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code207Q00000X
TaxonomyFamily Medicine Physician
License Number33240
License Number StateAZ
# 2
Primary TaxonomyY
Taxonomy Code207Q00000X
TaxonomyFamily Medicine Physician
License Number46597
License Number StateWA
# 3
Primary TaxonomyN
Taxonomy Code207Q00000X
TaxonomyFamily Medicine Physician
License NumberMD27358
License Number StateOR

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: