Provider Demographics
NPI:1053334896
Name:WHITFIELD, ALAN (PT)
Entity Type:Individual
Prefix:
First Name:ALAN
Middle Name:
Last Name:WHITFIELD
Suffix:
Gender:M
Credentials:PT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1325 E FORTIFICATION ST
Mailing Address - Street 2:
Mailing Address - City:JACKSON
Mailing Address - State:MS
Mailing Address - Zip Code:39202-2442
Mailing Address - Country:US
Mailing Address - Phone:601-949-9110
Mailing Address - Fax:601-949-9113
Practice Address - Street 1:1325 E FORTIFICATION ST
Practice Address - Street 2:
Practice Address - City:JACKSON
Practice Address - State:MS
Practice Address - Zip Code:39202-2442
Practice Address - Country:US
Practice Address - Phone:601-949-9110
Practice Address - Fax:601-949-9113
Is Sole Proprietor?:No
Enumeration Date:2006-07-25
Last Update Date:2011-11-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MSPT17172081S0010X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2081S0010XAllopathic & Osteopathic PhysiciansPhysical Medicine & RehabilitationSports Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
MS07430508Medicaid
MSP00350407OtherMEDICARE RR
MS0765100001Medicare NSC
MS650000346Medicare PIN