Provider Demographics
NPI:1053304782
Name:WHITEHURST, SUSAN J (MD)
Entity Type:Individual
Prefix:
First Name:SUSAN
Middle Name:J
Last Name:WHITEHURST
Suffix:
Gender:F
Credentials:MD
Other - Prefix:
Other - First Name:JANICE
Other - Middle Name:SUSAN
Other - Last Name:JOHNSON-WHITEHURST
Other - Suffix:
Other - Last Name Type:Professional Name
Other - Credentials:MD
Mailing Address - Street 1:130 THORNOAK DR
Mailing Address - Street 2:
Mailing Address - City:MARTIN
Mailing Address - State:TN
Mailing Address - Zip Code:38237-1415
Mailing Address - Country:US
Mailing Address - Phone:731-225-4017
Mailing Address - Fax:731-227-6050
Practice Address - Street 1:130 THORNOAK DR
Practice Address - Street 2:
Practice Address - City:MARTIN
Practice Address - State:TN
Practice Address - Zip Code:38237-1415
Practice Address - Country:US
Practice Address - Phone:731-587-6743
Practice Address - Fax:731-587-6743
Is Sole Proprietor?:Yes
Enumeration Date:2005-08-29
Last Update Date:2023-06-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TN7529174400000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes174400000XOther Service ProvidersSpecialist
Provider Identifiers
StateIdentifier IDID TypeIssuer
TN3156657Medicare ID - Type Unspecified
TNB02642Medicare UPIN