Provider Demographics
NPI:1235239146
Name:WHITACRE, ERIC B (MD)
Entity Type:Individual
Prefix:
First Name:ERIC
Middle Name:B
Last Name:WHITACRE
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:PO BOX 43130
Mailing Address - Street 2:
Mailing Address - City:TUCSON
Mailing Address - State:AZ
Mailing Address - Zip Code:85733-3130
Mailing Address - Country:US
Mailing Address - Phone:520-722-3777
Mailing Address - Fax:520-296-6224
Practice Address - Street 1:5230 E FARNESS DR
Practice Address - Street 2:SUITE 104
Practice Address - City:TUCSON
Practice Address - State:AZ
Practice Address - Zip Code:85712-2141
Practice Address - Country:US
Practice Address - Phone:520-319-6686
Practice Address - Fax:520-319-6696
Is Sole Proprietor?:Yes
Enumeration Date:2006-09-22
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AZ32120208600000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208600000XAllopathic & Osteopathic PhysiciansSurgery
Provider Identifiers
StateIdentifier IDID TypeIssuer
102908Medicare ID - Type Unspecified
E76016Medicare UPIN