Provider Demographics
NPI:1528012028
Name:WHITEHEAD, BRENT E (MD)
Entity Type:Individual
Prefix:
First Name:BRENT
Middle Name:E
Last Name:WHITEHEAD
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:PO BOX 5096
Mailing Address - Street 2:
Mailing Address - City:BELLINGHAM
Mailing Address - State:WA
Mailing Address - Zip Code:98227-5096
Mailing Address - Country:US
Mailing Address - Phone:360-738-2200
Mailing Address - Fax:360-752-5686
Practice Address - Street 1:4545 CORDATA PKWY
Practice Address - Street 2:
Practice Address - City:BELLINGHAM
Practice Address - State:WA
Practice Address - Zip Code:98226-7123
Practice Address - Country:US
Practice Address - Phone:360-738-2200
Practice Address - Fax:360-752-5686
Is Sole Proprietor?:No
Enumeration Date:2006-05-19
Last Update Date:2023-10-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA89965207Q00000X
WAMD00046649207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
WA0229987OtherL&I AND CRIME VICTIMS
WA1528012028Medicaid
WA2854WHOtherREGENCE
WA7097802OtherAETNA
WA8457681Medicaid
WAP00607300OtherRAILROAD MEDICARE
WA0229987OtherL&I AND CRIME VICTIMS
WA7097802OtherAETNA