Provider Demographics
NPI:1093733719
Name:WHITLEY, WILLIAM H (DO)
Entity Type:Individual
Prefix:
First Name:WILLIAM
Middle Name:H
Last Name:WHITLEY
Suffix:
Gender:M
Credentials:DO
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1724 VILLAGE PARK DR
Mailing Address - Street 2:
Mailing Address - City:ORANGEBURG
Mailing Address - State:SC
Mailing Address - Zip Code:29118-2426
Mailing Address - Country:US
Mailing Address - Phone:803-531-6004
Mailing Address - Fax:803-531-0103
Practice Address - Street 1:1724 VILLAGE PARK DR
Practice Address - Street 2:
Practice Address - City:ORANGEBURG
Practice Address - State:SC
Practice Address - Zip Code:29118-2426
Practice Address - Country:US
Practice Address - Phone:803-531-6004
Practice Address - Fax:803-531-0103
Is Sole Proprietor?:Yes
Enumeration Date:2006-07-18
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
SC0371207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
SCT00816Medicaid
SCT00816Medicaid