Provider Demographics
NPI:1023004439
Name:WHIGHTSEL, JEFFREY WAYNE (MD)
Entity Type:Individual
Prefix:
First Name:JEFFREY
Middle Name:WAYNE
Last Name:WHIGHTSEL
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:PO BOX 784
Mailing Address - Street 2:
Mailing Address - City:EFFINGHAM
Mailing Address - State:IL
Mailing Address - Zip Code:62401-0784
Mailing Address - Country:US
Mailing Address - Phone:217-342-3337
Mailing Address - Fax:217-347-3328
Practice Address - Street 1:912 N HENRIETTA ST
Practice Address - Street 2:
Practice Address - City:EFFINGHAM
Practice Address - State:IL
Practice Address - Zip Code:62401-1788
Practice Address - Country:US
Practice Address - Phone:217-342-3337
Practice Address - Fax:217-347-3328
Is Sole Proprietor?:Yes
Enumeration Date:2005-09-21
Last Update Date:2017-03-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL036-085757207V00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207V00000XAllopathic & Osteopathic PhysiciansObstetrics & GynecologyGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
IL036085757Medicaid
ILF400210126Medicare PIN
IL036085757Medicaid