Provider Demographics
NPI:1568448397
Name:WHEALTON, EDWARD GORDON (MD)
Entity Type:Individual
Prefix:
First Name:EDWARD
Middle Name:GORDON
Last Name:WHEALTON
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 1:1011 EDEN WAY N
Mailing Address - Street 2:SUITE H
Mailing Address - City:CHESAPEAKE
Mailing Address - State:VA
Mailing Address - Zip Code:23320-2768
Mailing Address - Country:US
Mailing Address - Phone:757-953-6366
Mailing Address - Fax:
Practice Address - Street 1:TRICARE PRIME CLINIC CHESAPEAKE
Practice Address - Street 2:1011 EDEN WAY NORTH SUITE H
Practice Address - City:CHESAPEAKE
Practice Address - State:VA
Practice Address - Zip Code:23320
Practice Address - Country:US
Practice Address - Phone:757-953-6366
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2005-12-22
Last Update Date:2011-06-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
VA0101056451207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine