Provider Demographics
NPI:1629136684
Name:WHITAKER, SAMUEL ROBINSON (MD)
Entity Type:Individual
Prefix:DR
First Name:SAMUEL
Middle Name:ROBINSON
Last Name:WHITAKER
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 1:1041 S GARFIELD AVE
Mailing Address - Street 2:STE 207
Mailing Address - City:ALHAMBRA
Mailing Address - State:CA
Mailing Address - Zip Code:91801-4765
Mailing Address - Country:US
Mailing Address - Phone:626-872-0192
Mailing Address - Fax:626-872-0194
Practice Address - Street 1:1041 S GARFIELD AVE
Practice Address - Street 2:STE 207
Practice Address - City:ALHAMBRA
Practice Address - State:CA
Practice Address - Zip Code:91801-4765
Practice Address - Country:US
Practice Address - Phone:626-872-0192
Practice Address - Fax:626-872-0194
Is Sole Proprietor?:Yes
Enumeration Date:2006-12-04
Last Update Date:2015-02-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAG44301207Y00000X, 207YX0901X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207YX0901XAllopathic & Osteopathic PhysiciansOtolaryngologyOtology & Neurotology
No207Y00000XAllopathic & Osteopathic PhysiciansOtolaryngology
Provider Identifiers
StateIdentifier IDID TypeIssuer
CA00G443010Medicaid
CAG44301OtherCA STATE LICENSE
CA35479Medicare PIN
CAA49608Medicare UPIN