Provider Demographics
NPI:1033104344
Name:WHITESIDES, EDWARD W (MD)
Entity Type:Individual
Prefix:DR
First Name:EDWARD
Middle Name:W
Last Name:WHITESIDES
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 1:1905 GLEN MEADE RD
Mailing Address - Street 2:
Mailing Address - City:WILMINGTON
Mailing Address - State:NC
Mailing Address - Zip Code:28403-6024
Mailing Address - Country:US
Mailing Address - Phone:910-763-6251
Mailing Address - Fax:910-763-7408
Practice Address - Street 1:1905 GLEN MEADE RD
Practice Address - Street 2:
Practice Address - City:WILMINGTON
Practice Address - State:NC
Practice Address - Zip Code:28403-6024
Practice Address - Country:US
Practice Address - Phone:910-763-6251
Practice Address - Fax:910-763-7408
Is Sole Proprietor?:No
Enumeration Date:2005-09-13
Last Update Date:2023-12-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MDD98830208800000X
NC36671174400000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes174400000XOther Service ProvidersSpecialist
No208800000XAllopathic & Osteopathic PhysiciansUrology
Provider Identifiers
StateIdentifier IDID TypeIssuer
NC79-87180Medicaid
NC79-87180Medicaid
NCF58921Medicare UPIN