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General NPI Number Information
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NPI Number | 1114363108
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Entity Type | Organization
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Legal Business Name | JOHN R. WHITTAKER, M.D., PLLC
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Dates
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Enumeration Date | 05/16/2013
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Last Update Date | 05/16/2013
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Provider Practice Location Address
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Address Line | 20240 W 12 MILE RD SUITE 3
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City | SOUTHFIELD
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State | MI
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Zip | 48076-2426
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Country | US
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Telephone | 248-423-0903
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Fax | 248-423-0905
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Provider Business Mailing Address
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Address Line | 6431 BAUERVIC BLVD
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City | WEST BLOOMFIELD
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State | MI
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Zip | 48322-2237
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Country | US
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Telephone | 248-851-0635
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Fax | 248-851-6463
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Authorized Official
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Title or Position | PRESIDENT
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Name | JOHN RAYMOND WHITTAKER
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Credential | M.D.
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Telephone | 248-423-0903
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 208600000X
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Taxonomy Name | Surgery Physician
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License Number | 4301039465
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License Number State | MI
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