Provider Demographics
NPI:1164413167
Name:WHITAKER, THEODORE M (DO)
Entity Type:Individual
Prefix:
First Name:THEODORE
Middle Name:M
Last Name:WHITAKER
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 1:12140 NALL AVE STE 100
Mailing Address - Street 2:
Mailing Address - City:OVERLAND PARK
Mailing Address - State:KS
Mailing Address - Zip Code:66209-2504
Mailing Address - Country:US
Mailing Address - Phone:816-943-0406
Mailing Address - Fax:913-451-1754
Practice Address - Street 1:12140 NALL AVE STE 100
Practice Address - Street 2:
Practice Address - City:OVERLAND PARK
Practice Address - State:KS
Practice Address - Zip Code:66209-2504
Practice Address - Country:US
Practice Address - Phone:816-943-0406
Practice Address - Fax:913-451-1754
Is Sole Proprietor?:No
Enumeration Date:2005-10-31
Last Update Date:2018-03-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MOR1D87207R00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207R00000XAllopathic & Osteopathic PhysiciansInternal Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
MO242039642Medicaid
MO5238405Medicare ID - Type UnspecifiedMEDICARE - MO AND KS
MOE92139Medicare UPIN