Provider Demographics
NPI:1457492209
Name:WHITTAKER, JOHN ROGER (MD)
Entity Type:Individual
Prefix:
First Name:JOHN
Middle Name:ROGER
Last Name:WHITTAKER
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 1:710 LOMAX ST
Mailing Address - Street 2:
Mailing Address - City:JACKSONVILLE
Mailing Address - State:FL
Mailing Address - Zip Code:32204-4004
Mailing Address - Country:US
Mailing Address - Phone:904-355-6583
Mailing Address - Fax:904-355-4922
Practice Address - Street 1:710 LOMAX ST
Practice Address - Street 2:
Practice Address - City:JACKSONVILLE
Practice Address - State:FL
Practice Address - Zip Code:32204-4004
Practice Address - Country:US
Practice Address - Phone:904-355-6583
Practice Address - Fax:904-355-4922
Is Sole Proprietor?:Yes
Enumeration Date:2007-02-12
Last Update Date:2008-05-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLME25510208800000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208800000XAllopathic & Osteopathic PhysiciansUrology
Provider Identifiers
StateIdentifier IDID TypeIssuer
FL045080400Medicaid
FL55062ZMedicare ID - Type Unspecified
FLD65121Medicare UPIN