Provider Demographics
NPI:1083032528
Name:WHITESIDES, DANIEL BENNETT (MD)
Entity Type:Individual
Prefix:
First Name:DANIEL
Middle Name:BENNETT
Last Name:WHITESIDES
Suffix:
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 1:632 BROADWAY PH 12
Mailing Address - Street 2:
Mailing Address - City:NEW YORK
Mailing Address - State:NY
Mailing Address - Zip Code:10012-2614
Mailing Address - Country:US
Mailing Address - Phone:347-294-3414
Mailing Address - Fax:
Practice Address - Street 1:107 SUNNYBROOK RD STE 159
Practice Address - Street 2:
Practice Address - City:RALEIGH
Practice Address - State:NC
Practice Address - Zip Code:27610-1827
Practice Address - Country:US
Practice Address - Phone:984-974-4832
Practice Address - Fax:984-974-4920
Is Sole Proprietor?:No
Enumeration Date:2014-04-02
Last Update Date:2023-03-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAA139934207Q00000X
390200000X
NC2022-03191207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
No390200000XStudent, Health CareStudent in an Organized Health Care Education/Training Program