Provider Demographics
NPI:1538126156
Name:WHITLOCK, WARREN O JR (MD)
Entity Type:Individual
Prefix:DR
First Name:WARREN
Middle Name:O
Last Name:WHITLOCK
Suffix:JR
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:
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Mailing Address - Street 1:130 HEALTH PARK BLVD
Mailing Address - Street 2:
Mailing Address - City:ST AUGUSTINE
Mailing Address - State:FL
Mailing Address - Zip Code:32086-5776
Mailing Address - Country:US
Mailing Address - Phone:904-826-3469
Mailing Address - Fax:904-808-4608
Practice Address - Street 1:130 HEALTH PARK BLVD
Practice Address - Street 2:
Practice Address - City:ST AUGUSTINE
Practice Address - State:FL
Practice Address - Zip Code:32086-5776
Practice Address - Country:US
Practice Address - Phone:904-826-3469
Practice Address - Fax:904-808-4608
Is Sole Proprietor?:No
Enumeration Date:2006-04-27
Last Update Date:2008-07-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLME34534207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
FL080096188OtherPALMETTO GBA RAILROAD MED
FL038458500Medicaid
FL55108ZMedicare PIN
FL080096188OtherPALMETTO GBA RAILROAD MED