Provider Demographics
NPI:1487630919
Name:WHITEHEAD, RICHARD JAMES JR (PAC)
Entity Type:Individual
Prefix:
First Name:RICHARD
Middle Name:JAMES
Last Name:WHITEHEAD
Suffix:JR
Gender:M
Credentials:PAC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:410 SAYBROOK RD
Mailing Address - Street 2:SUITE 201
Mailing Address - City:MIDDLETOWN
Mailing Address - State:CT
Mailing Address - Zip Code:06457
Mailing Address - Country:US
Mailing Address - Phone:860-347-4620
Mailing Address - Fax:860-346-9687
Practice Address - Street 1:410 SAYBROOK RD
Practice Address - Street 2:SUITE 201
Practice Address - City:MIDDLETOWN
Practice Address - State:CT
Practice Address - Zip Code:06457-4777
Practice Address - Country:US
Practice Address - Phone:860-347-4620
Practice Address - Fax:860-344-5995
Is Sole Proprietor?:No
Enumeration Date:2005-12-16
Last Update Date:2015-03-25
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CT000881363AM0700X
CT0000881363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant
No363AM0700XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician AssistantMedical
Provider Identifiers
StateIdentifier IDID TypeIssuer
CT970000994Medicare ID - Type Unspecified
P08862Medicare UPIN