Provider Demographics
NPI:1679524193
Name:WHITLEY, GWENDOLYN RUTH (MD)
Entity Type:Individual
Prefix:DR
First Name:GWENDOLYN
Middle Name:RUTH
Last Name:WHITLEY
Suffix:
Gender:F
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:257 BRANCHWOOD CIR NE
Mailing Address - Street 2:
Mailing Address - City:CONCORD
Mailing Address - State:NC
Mailing Address - Zip Code:28025-3103
Mailing Address - Country:US
Mailing Address - Phone:704-701-1007
Mailing Address - Fax:704-262-3375
Practice Address - Street 1:257 BRANCHWOOD CIR NE
Practice Address - Street 2:
Practice Address - City:CONCORD
Practice Address - State:NC
Practice Address - Zip Code:28025-3103
Practice Address - Country:US
Practice Address - Phone:704-701-1007
Practice Address - Fax:704-262-3375
Is Sole Proprietor?:Not Answered
Enumeration Date:2006-05-12
Last Update Date:2023-03-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MN46430207PE0004X
WI175868207PE0004X
NC37585207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Not Answered207PE0004XAllopathic & Osteopathic PhysiciansEmergency MedicineEmergency Medical Services
Not Answered207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
MN46430OtherMN MEDICAL LICENSE
WI175868OtherWISCONSIN MEDICAL LICENSE
NC37685OtherNC MEDICAL LICENSE NUMBER
NC37685OtherNC MEDICAL LICENSE NUMBER
NCBW1064473OtherDEA NUMBER