Provider Demographics
NPI:1508809625
Name:WHITAKER, LEE CARL (MD)
Entity Type:Individual
Prefix:DR
First Name:LEE
Middle Name:CARL
Last Name:WHITAKER
Suffix:
Gender:M
Credentials:MD
Other - Prefix:DR
Other - First Name:LEE
Other - Middle Name:C
Other - Last Name:WHITAKER
Other - Suffix:
Other - Last Name Type:Professional Name
Other - Credentials:MD, MPH
Mailing Address - Street 1:PO BOX 7425
Mailing Address - Street 2:
Mailing Address - City:ST THOMAS
Mailing Address - State:VI
Mailing Address - Zip Code:00801-0425
Mailing Address - Country:US
Mailing Address - Phone:340-777-1996
Mailing Address - Fax:
Practice Address - Street 1:1901 9TH STREET
Practice Address - Street 2:
Practice Address - City:ST THOMAS
Practice Address - State:VI
Practice Address - Zip Code:00802-0000
Practice Address - Country:US
Practice Address - Phone:340-777-1996
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2006-06-14
Last Update Date:2012-05-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TNMD000035229207Q00000X
VI1625207QA0505X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207QA0505XAllopathic & Osteopathic PhysiciansFamily MedicineAdult Medicine
No207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
TN1508809625OtherNPI
AL009911897Medicaid
TN1016710001Medicare NSC
TNG81913Medicare UPIN
TN3830062Medicare PIN