Provider Demographics
NPI:1073707071
Name:WHITEHEAD, ANTONETTE OTIS (MD)
Entity Type:Individual
Prefix:DR
First Name:ANTONETTE
Middle Name:OTIS
Last Name:WHITEHEAD
Suffix:
Gender:F
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:568 BROADWAY
Mailing Address - Street 2:SUITE 304
Mailing Address - City:NEW YORK
Mailing Address - State:NY
Mailing Address - Zip Code:10012-3225
Mailing Address - Country:US
Mailing Address - Phone:313-215-3088
Mailing Address - Fax:
Practice Address - Street 1:568 BROADWAY
Practice Address - Street 2:SUITE 304
Practice Address - City:NEW YORK
Practice Address - State:NY
Practice Address - Zip Code:10012-3225
Practice Address - Country:US
Practice Address - Phone:313-215-3088
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2007-09-02
Last Update Date:2013-12-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL126062497207V00000X
NY261819207V00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207V00000XAllopathic & Osteopathic PhysiciansObstetrics & Gynecology