Provider Demographics
NPI:1366477168
Name:WHITAKER, GARY W (DC)
Entity Type:Individual
Prefix:DR
First Name:GARY
Middle Name:W
Last Name:WHITAKER
Suffix:
Gender:M
Credentials:DC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2422 E GRIFFIN PKWY
Mailing Address - Street 2:
Mailing Address - City:MISSION
Mailing Address - State:TX
Mailing Address - Zip Code:78572-3302
Mailing Address - Country:US
Mailing Address - Phone:956-584-7388
Mailing Address - Fax:956-584-7328
Practice Address - Street 1:2422 E GRIFFIN PKWY
Practice Address - Street 2:
Practice Address - City:MISSION
Practice Address - State:TX
Practice Address - Zip Code:78572-3302
Practice Address - Country:US
Practice Address - Phone:956-584-7388
Practice Address - Fax:956-584-7328
Is Sole Proprietor?:Yes
Enumeration Date:2006-07-11
Last Update Date:2012-05-31
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TX2912111N00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes111N00000XChiropractic ProvidersChiropractor
Provider Identifiers
StateIdentifier IDID TypeIssuer
TX0011579-01Medicaid
TX8F0749Medicare PIN
TX601154Medicare PIN
TX0011579-01Medicaid