Provider Demographics
NPI:1285666487
Name:WHITTON, GERALD BRENT (MD)
Entity Type:Individual
Prefix:
First Name:GERALD
Middle Name:BRENT
Last Name:WHITTON
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 3038
Mailing Address - Street 2:
Mailing Address - City:SHREVEPORT
Mailing Address - State:LA
Mailing Address - Zip Code:71133-3038
Mailing Address - Country:US
Mailing Address - Phone:318-212-5970
Mailing Address - Fax:318-212-5975
Practice Address - Street 1:2510 BERT KOUNS INDUSTRIAL LOOP STE 215
Practice Address - Street 2:
Practice Address - City:SHREVEPORT
Practice Address - State:LA
Practice Address - Zip Code:71118-3119
Practice Address - Country:US
Practice Address - Phone:318-212-5970
Practice Address - Fax:318-212-5975
Is Sole Proprietor?:No
Enumeration Date:2006-07-07
Last Update Date:2021-06-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
LA0244592080N0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2080N0001XAllopathic & Osteopathic PhysiciansPediatricsNeonatal-Perinatal Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
LA1572179Medicaid
LA1572179Medicaid