Provider Demographics
NPI:1760582266
Name:WHITTINGTON, JOHN
Entity Type:Individual
Prefix:
First Name:JOHN
Middle Name:
Last Name:WHITTINGTON
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:800 NE GLEN OAK AVE
Mailing Address - Street 2:
Mailing Address - City:PEORIA
Mailing Address - State:IL
Mailing Address - Zip Code:61603-3255
Mailing Address - Country:US
Mailing Address - Phone:309-683-5987
Mailing Address - Fax:309-683-5969
Practice Address - Street 1:800 NE GLEN OAK AVE
Practice Address - Street 2:
Practice Address - City:PEORIA
Practice Address - State:IL
Practice Address - Zip Code:61603-3255
Practice Address - Country:US
Practice Address - Phone:309-683-5987
Practice Address - Fax:309-683-5969
Is Sole Proprietor?:No
Enumeration Date:2006-09-24
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
C42108Medicare UPIN
833130Medicare ID - Type Unspecified
ILCA2264Medicare ID - Type UnspecifiedRR GROUP #
ILK29720Medicare ID - Type UnspecifiedINDIVIDUAL