Provider Demographics
NPI:1609870682
Name:WHITLEY, BRENT J (MD)
Entity Type:Individual
Prefix:
First Name:BRENT
Middle Name:J
Last Name:WHITLEY
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:PO BOX 551014
Mailing Address - Street 2:
Mailing Address - City:TAMPA
Mailing Address - State:FL
Mailing Address - Zip Code:33655-1014
Mailing Address - Country:US
Mailing Address - Phone:800-476-8646
Mailing Address - Fax:919-382-3210
Practice Address - Street 1:5757 N DIXIE HWY
Practice Address - Street 2:
Practice Address - City:OAKLAND PARK
Practice Address - State:FL
Practice Address - Zip Code:33334-4135
Practice Address - Country:US
Practice Address - Phone:954-776-6000
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2005-06-08
Last Update Date:2021-04-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLME67493207P00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207P00000XAllopathic & Osteopathic PhysiciansEmergency Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
FL26888OtherBCBS
FL080072358OtherRAILROAD MEDICARE
FL378096100Medicaid