Provider Demographics
NPI:1790751261
Name:WHITEHEAD, A JEFFREY (MD)
Entity Type:Individual
Prefix:
First Name:A
Middle Name:JEFFREY
Last Name:WHITEHEAD
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:ALLAN
Other - Middle Name:JEFFREY
Other - Last Name:WHITEHEAD
Other - Suffix:
Other - Last Name Type:Other Name
Other - Credentials:
Mailing Address - Street 1:3524 E MILWAUKEE ST
Mailing Address - Street 2:
Mailing Address - City:JANESVILLE
Mailing Address - State:WI
Mailing Address - Zip Code:53546-1626
Mailing Address - Country:US
Mailing Address - Phone:608-756-7100
Mailing Address - Fax:608-756-4700
Practice Address - Street 1:3524 E MILWAUKEE ST
Practice Address - Street 2:
Practice Address - City:JANESVILLE
Practice Address - State:WI
Practice Address - Zip Code:53546-1626
Practice Address - Country:US
Practice Address - Phone:608-756-7100
Practice Address - Fax:608-756-4700
Is Sole Proprietor?:No
Enumeration Date:2006-02-24
Last Update Date:2012-09-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WI47003207W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207W00000XAllopathic & Osteopathic PhysiciansOphthalmology
Provider Identifiers
StateIdentifier IDID TypeIssuer
WIWHITEJE4OtherMERCYCARE INSURANCE
WI34551500Medicaid
WIP00942387DB7792OtherRR MEDICARE
WIWHITEJE4OtherMERCYCARE INSURANCE
WI34551500Medicaid
WIP00942387DB7792OtherRR MEDICARE
WIWHITEJE4OtherMERCYCARE INSURANCE
I15522Medicare UPIN