Provider Demographics
NPI:1386657336
Name:WHITEHEAD, WILLARD III (MD)
Entity Type:Individual
Prefix:
First Name:WILLARD
Middle Name:
Last Name:WHITEHEAD
Suffix:III
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 1:415 MULBERRY ST
Mailing Address - Street 2:
Mailing Address - City:EVANSVILLE
Mailing Address - State:IN
Mailing Address - Zip Code:47713-1230
Mailing Address - Country:US
Mailing Address - Phone:812-423-7791
Mailing Address - Fax:812-422-7558
Practice Address - Street 1:415 MULBERRY ST
Practice Address - Street 2:
Practice Address - City:EVANSVILLE
Practice Address - State:IN
Practice Address - Zip Code:47713-1230
Practice Address - Country:US
Practice Address - Phone:812-423-7791
Practice Address - Fax:812-422-7558
Is Sole Proprietor?:No
Enumeration Date:2006-08-14
Last Update Date:2023-03-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IN01040185A2084P0800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2084P0800XAllopathic & Osteopathic PhysiciansPsychiatry & NeurologyPsychiatry
Provider Identifiers
StateIdentifier IDID TypeIssuer
IN260031376OtherRAILROAD MEDICARE
IN834950LLLOtherMEDICARE
IN01040185BOtherCSR
IN100366260Medicaid
IN000000082157OtherANTHEM
IN10787143OtherCAQH
IN10787143OtherCAQH
IN260031376OtherRAILROAD MEDICARE