Provider Demographics
NPI:1588607485
Name:WHELAN, DOUGLAS M (MD)
Entity type:Individual
Prefix:DR
First Name:DOUGLAS
Middle Name:M
Last Name:WHELAN
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 1:790 14TH AVE
Mailing Address - Street 2:
Mailing Address - City:LONGVIEW
Mailing Address - State:WA
Mailing Address - Zip Code:98632
Mailing Address - Country:US
Mailing Address - Phone:360-423-2450
Mailing Address - Fax:360-425-4969
Practice Address - Street 1:790 14TH AVE
Practice Address - Street 2:
Practice Address - City:LONGVIEW
Practice Address - State:WA
Practice Address - Zip Code:98632
Practice Address - Country:US
Practice Address - Phone:360-423-2450
Practice Address - Fax:360-425-4969
Is Sole Proprietor?:Yes
Enumeration Date:2006-06-14
Last Update Date:2010-08-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WAMD00026709174400000X
WA26709207V00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207V00000XAllopathic & Osteopathic PhysiciansObstetrics & Gynecology
No174400000XOther Service ProvidersSpecialist
Provider Identifiers
StateIdentifier IDID TypeIssuer
WA1150119Medicaid
000700226Medicare PIN
WAE57471Medicare UPIN