Provider Demographics
NPI:1326124595
Name:WHITAKER, NELLIE LAVERN (MD)
Entity Type:Individual
Prefix:
First Name:NELLIE
Middle Name:LAVERN
Last Name:WHITAKER
Suffix:
Gender:F
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1667 CROFTONCENTRE
Mailing Address - Street 2:SUITE 1
Mailing Address - City:CROFTON
Mailing Address - State:MD
Mailing Address - Zip Code:21114
Mailing Address - Country:US
Mailing Address - Phone:410-721-2700
Mailing Address - Fax:410-721-8874
Practice Address - Street 1:1667 CROFTONCENTRE
Practice Address - Street 2:SUITE 1
Practice Address - City:CROFTON
Practice Address - State:MD
Practice Address - Zip Code:21114
Practice Address - Country:US
Practice Address - Phone:410-721-2700
Practice Address - Fax:410-721-8874
Is Sole Proprietor?:No
Enumeration Date:2006-10-31
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MDD0028436208D00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208D00000XAllopathic & Osteopathic PhysiciansGeneral Practice
Provider Identifiers
StateIdentifier IDID TypeIssuer
MDE52421Medicare UPIN
039N881FMedicare ID - Type Unspecified