Provider Demographics
NPI:1598879116
Name:WHITENECK, THOMAS M (DO)
Entity Type:Individual
Prefix:DR
First Name:THOMAS
Middle Name:M
Last Name:WHITENECK
Suffix:
Gender:M
Credentials:DO
Other - Prefix:
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Other - Middle Name:
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Other - Credentials:
Mailing Address - Street 1:1730 LAWRENCEVILLE SUWANEE RD
Mailing Address - Street 2:
Mailing Address - City:LAWRENCEVILLE
Mailing Address - State:GA
Mailing Address - Zip Code:30043-3507
Mailing Address - Country:US
Mailing Address - Phone:770-338-0089
Mailing Address - Fax:770-338-0091
Practice Address - Street 1:1730 LAWRENCEVILLE SUWANEE RD
Practice Address - Street 2:
Practice Address - City:LAWRENCEVILLE
Practice Address - State:GA
Practice Address - Zip Code:30043-3507
Practice Address - Country:US
Practice Address - Phone:770-338-0089
Practice Address - Fax:770-338-0091
Is Sole Proprietor?:No
Enumeration Date:2006-08-19
Last Update Date:2011-05-18
Deactivation Date:
Deactivation Code:
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Provider Licenses
StateLicense IDTaxonomies
GA034077207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
GA511I080663Medicare PIN
GAE99247Medicare UPIN