Provider Demographics
NPI:1568517662
Name:WHITEHEAD, RICHARD EARL (MD)
Entity Type:Individual
Prefix:DR
First Name:RICHARD
Middle Name:EARL
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 1:2550 HARBOURSIDE DR
Mailing Address - Street 2:#344
Mailing Address - City:LONGBOAT KEY
Mailing Address - State:FL
Mailing Address - Zip Code:34228-4170
Mailing Address - Country:US
Mailing Address - Phone:941-383-0573
Mailing Address - Fax:
Practice Address - Street 1:2550 HARBOURSIDE DR
Practice Address - Street 2:#344
Practice Address - City:LONGBOAT KEY
Practice Address - State:FL
Practice Address - Zip Code:34228-4170
Practice Address - Country:US
Practice Address - Phone:941-383-0573
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2007-01-25
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
KS04-13233207X00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207X00000XAllopathic & Osteopathic PhysiciansOrthopaedic Surgery
Provider Identifiers
StateIdentifier IDID TypeIssuer
KSC51250Medicare UPIN