Provider Demographics
NPI:1467461764
Name:WHITAKER, JOHN C (MD)
Entity Type:Individual
Prefix:DR
First Name:JOHN
Middle Name:C
Last Name:WHITAKER
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 1:2713 S 74TH ST
Mailing Address - Street 2:SUITE 408
Mailing Address - City:FORT SMITH
Mailing Address - State:AR
Mailing Address - Zip Code:72903-5170
Mailing Address - Country:US
Mailing Address - Phone:479-484-5646
Mailing Address - Fax:
Practice Address - Street 1:2713 S 74TH ST
Practice Address - Street 2:SUITE 408
Practice Address - City:FORT SMITH
Practice Address - State:AR
Practice Address - Zip Code:72903-5170
Practice Address - Country:US
Practice Address - Phone:479-484-5646
Practice Address - Fax:479-242-2323
Is Sole Proprietor?:Yes
Enumeration Date:2006-08-05
Last Update Date:2011-04-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
ARC-7165208000000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208000000XAllopathic & Osteopathic PhysiciansPediatrics
Provider Identifiers
StateIdentifier IDID TypeIssuer
AR115671001Medicaid
AR115671001Medicaid
AR52893Medicare ID - Type Unspecified