Provider Demographics
NPI:1659350908
Name:WHITLEY, HERBERT (MD)
Entity Type:Individual
Prefix:
First Name:HERBERT
Middle Name:
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 1:1928 SPRINGMILL RD
Mailing Address - Street 2:
Mailing Address - City:SALEM
Mailing Address - State:VA
Mailing Address - Zip Code:24153-4703
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:102 HIGHLAND AVE SE
Practice Address - Street 2:
Practice Address - City:ROANOKE
Practice Address - State:VA
Practice Address - Zip Code:24013-2255
Practice Address - Country:US
Practice Address - Phone:540-224-4545
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2006-01-14
Last Update Date:2011-08-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
VA0101-2310792080P0202X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2080P0202XAllopathic & Osteopathic PhysiciansPediatricsPediatric Cardiology
Provider Identifiers
StateIdentifier IDID TypeIssuer
VA010264197Medicaid
VA6736661Medicaid
VA6720269Medicaid
VA6725104Medicaid
VA6736653Medicaid
VA6736688Medicaid
VA6736670Medicaid
VA6739636Medicaid
VA6736661Medicaid
VA6736653Medicaid
VA6739636Medicaid