Provider Demographics
NPI:1700840055
Name:WHITLEY, MARK EMORY (MD)
Entity Type:Individual
Prefix:
First Name:MARK
Middle Name:EMORY
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 1:3600 NW 138TH ST
Mailing Address - Street 2:SUITE 102
Mailing Address - City:OKLAHOMA CITY
Mailing Address - State:OK
Mailing Address - Zip Code:73134-2503
Mailing Address - Country:US
Mailing Address - Phone:405-286-4114
Mailing Address - Fax:405-463-0154
Practice Address - Street 1:3600 NW 138TH ST
Practice Address - Street 2:SUITE 102
Practice Address - City:OKLAHOMA CITY
Practice Address - State:OK
Practice Address - Zip Code:73134-2503
Practice Address - Country:US
Practice Address - Phone:405-286-4114
Practice Address - Fax:405-463-0154
Is Sole Proprietor?:No
Enumeration Date:2006-04-13
Last Update Date:2014-11-04
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OK192272085R0202X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2085R0202XAllopathic & Osteopathic PhysiciansRadiologyDiagnostic Radiology
Provider Identifiers
StateIdentifier IDID TypeIssuer
OK100143910AMedicaid
OK100143910AMedicaid
OKF32413Medicare UPIN
OK247606701Medicare Oscar/Certification
OKP01029733Medicare PIN