Provider Demographics
NPI:1154322899
Name:WHITESELL, JANISE HARTZOG (MD)
Entity Type:Individual
Prefix:DR
First Name:JANISE
Middle Name:HARTZOG
Last Name:WHITESELL
Suffix:
Gender:F
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
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Other - Credentials:
Mailing Address - Street 1:2060 DAN PROCTOR DR
Mailing Address - Street 2:SUITE 2100
Mailing Address - City:SAINT MARYS
Mailing Address - State:GA
Mailing Address - Zip Code:31558-3894
Mailing Address - Country:US
Mailing Address - Phone:912-882-6767
Mailing Address - Fax:912-882-6411
Practice Address - Street 1:2060 DAN PROCTOR DR
Practice Address - Street 2:SUITE 2100
Practice Address - City:SAINT MARYS
Practice Address - State:GA
Practice Address - Zip Code:31558-3894
Practice Address - Country:US
Practice Address - Phone:912-882-6767
Practice Address - Fax:912-882-6411
Is Sole Proprietor?:No
Enumeration Date:2005-08-03
Last Update Date:2014-08-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GA047867207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
H42553Medicare UPIN
GA08BBXPKMedicare ID - Type Unspecified