Provider Demographics
NPI:1073592796
Name:WHITWORTH, CLAIBORNE GOOCH IV (MD)
Entity Type:Individual
Prefix:
First Name:CLAIBORNE
Middle Name:GOOCH
Last Name:WHITWORTH
Suffix:IV
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 1:213 S JEFFERSON ST STE 1006
Mailing Address - Street 2:
Mailing Address - City:ROANOKE
Mailing Address - State:VA
Mailing Address - Zip Code:24011-1713
Mailing Address - Country:US
Mailing Address - Phone:540-224-5715
Mailing Address - Fax:
Practice Address - Street 1:100 SPOTSWOOD DR
Practice Address - Street 2:
Practice Address - City:LEXINGTON
Practice Address - State:VA
Practice Address - Zip Code:24450-2454
Practice Address - Country:US
Practice Address - Phone:540-463-7108
Practice Address - Fax:540-462-2923
Is Sole Proprietor?:No
Enumeration Date:2006-01-11
Last Update Date:2022-08-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
VA0101049835208800000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208800000XAllopathic & Osteopathic PhysiciansUrology
Provider Identifiers
StateIdentifier IDID TypeIssuer
VA010080576Medicaid
137919OtherANTHEM/BLUE CROSS
54-0892025OtherTAX ID
137919OtherANTHEM/BLUE CROSS