Provider Demographics
NPI:1578572384
Name:WHITAKER, MARK D (DO)
Entity Type:Individual
Prefix:
First Name:MARK
Middle Name:D
Last Name:WHITAKER
Suffix:
Gender:M
Credentials:DO
Other - Prefix:
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Other - Credentials:
Mailing Address - Street 1:2500 W UTOPIA RD
Mailing Address - Street 2:STE. 100
Mailing Address - City:PHOENIX
Mailing Address - State:AZ
Mailing Address - Zip Code:85027-4171
Mailing Address - Country:US
Mailing Address - Phone:623-780-1999
Mailing Address - Fax:623-516-0950
Practice Address - Street 1:19636 N 27TH AVE
Practice Address - Street 2:SUITE 308
Practice Address - City:PHOENIX
Practice Address - State:AZ
Practice Address - Zip Code:85027-4013
Practice Address - Country:US
Practice Address - Phone:623-780-1999
Practice Address - Fax:623-516-0950
Is Sole Proprietor?:Yes
Enumeration Date:2006-08-08
Last Update Date:2015-02-02
Deactivation Date:
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Provider Licenses
StateLicense IDTaxonomies
AZ2347207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
AZ279704Medicaid
E83085Medicare UPIN
BCPLPMedicare ID - Type Unspecified