Provider Demographics
NPI:1598830663
Name:WHITT, CARL LEE (MD)
Entity Type:Individual
Prefix:DR
First Name:CARL
Middle Name:LEE
Last Name:WHITT
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 1:302 BROADWAY ST
Mailing Address - Street 2:
Mailing Address - City:NILES
Mailing Address - State:MI
Mailing Address - Zip Code:49120-2704
Mailing Address - Country:US
Mailing Address - Phone:269-683-1820
Mailing Address - Fax:
Practice Address - Street 1:302 BROADWAY ST
Practice Address - Street 2:
Practice Address - City:NILES
Practice Address - State:MI
Practice Address - Zip Code:49120-2704
Practice Address - Country:US
Practice Address - Phone:269-683-1820
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2006-11-22
Last Update Date:2007-07-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI4301050966174400000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes174400000XOther Service ProvidersSpecialist
Provider Identifiers
StateIdentifier IDID TypeIssuer
MI01109016022Medicare ID - Type UnspecifiedMEDICARE
MIA78394Medicare UPIN