Provider Demographics
NPI:1437195179
Name:WHITEHOUSE, WALTER M JR (MD)
Entity Type:Individual
Prefix:
First Name:WALTER
Middle Name:M
Last Name:WHITEHOUSE
Suffix:JR
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 1:5325 ELLIOTT DR
Mailing Address - Street 2:SUITE 104
Mailing Address - City:YPSILANTI
Mailing Address - State:MI
Mailing Address - Zip Code:48197-8633
Mailing Address - Country:US
Mailing Address - Phone:734-712-8150
Mailing Address - Fax:734-712-8151
Practice Address - Street 1:5325 ELLIOTT DR
Practice Address - Street 2:SUITE 104
Practice Address - City:YPSILANTI
Practice Address - State:MI
Practice Address - Zip Code:48197-8633
Practice Address - Country:US
Practice Address - Phone:734-712-8150
Practice Address - Fax:734-712-8151
Is Sole Proprietor?:No
Enumeration Date:2006-06-21
Last Update Date:2012-09-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI43010341572086S0129X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2086S0129XAllopathic & Osteopathic PhysiciansSurgeryVascular Surgery
Provider Identifiers
StateIdentifier IDID TypeIssuer
MI4146952-10Medicaid
MI4146952-10Medicaid
A79054Medicare UPIN