Provider Demographics
NPI:1073684296
Name:WHITNEY, THEODORE R JR (MD)
Entity Type:Individual
Prefix:DR
First Name:THEODORE
Middle Name:R
Last Name:WHITNEY
Suffix:JR
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
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Other - Credentials:
Mailing Address - Street 1:5301 CEDAR AVE
Mailing Address - Street 2:SUITE 226
Mailing Address - City:PHILADELPHIA
Mailing Address - State:PA
Mailing Address - Zip Code:19143-1917
Mailing Address - Country:US
Mailing Address - Phone:215-471-0600
Mailing Address - Fax:214-471-7032
Practice Address - Street 1:5301 CEDAR AVE
Practice Address - Street 2:SUITE 226
Practice Address - City:PHILADELPHIA
Practice Address - State:PA
Practice Address - Zip Code:19143-1917
Practice Address - Country:US
Practice Address - Phone:215-471-0600
Practice Address - Fax:214-471-7032
Is Sole Proprietor?:Yes
Enumeration Date:2006-11-10
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
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Provider Licenses
StateLicense IDTaxonomies
PAMD026440L208000000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208000000XAllopathic & Osteopathic PhysiciansPediatrics
Provider Identifiers
StateIdentifier IDID TypeIssuer
PA0688880Medicaid
PA0688880Medicaid
C27033Medicare UPIN