Provider Demographics
NPI:1861489759
Name:WHITAKER, WILLIE ROSCOE (MD)
Entity Type:Individual
Prefix:
First Name:WILLIE
Middle Name:ROSCOE
Last Name:WHITAKER
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 1:2117 SIMONTON RD
Mailing Address - Street 2:SUITE 102
Mailing Address - City:STATESVILLE
Mailing Address - State:NC
Mailing Address - Zip Code:28625-8403
Mailing Address - Country:US
Mailing Address - Phone:704-872-8422
Mailing Address - Fax:704-872-8705
Practice Address - Street 1:2117 SIMONTON RD
Practice Address - Street 2:SUITE 102
Practice Address - City:STATESVILLE
Practice Address - State:NC
Practice Address - Zip Code:28625-8403
Practice Address - Country:US
Practice Address - Phone:704-872-8422
Practice Address - Fax:704-872-8705
Is Sole Proprietor?:Yes
Enumeration Date:2005-10-05
Last Update Date:2014-03-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NCNC2003-00428207R00000X
NC2003-00428207RN0300X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207RN0300XAllopathic & Osteopathic PhysiciansInternal MedicineNephrology
No207R00000XAllopathic & Osteopathic PhysiciansInternal Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
NCC8620OtherMEDCOST
NC38354OtherPARTNERS' MEDICARE #
NC89134J6Medicaid
E73961OtherUPIN
NC134J6OtherBLUE CROSS BLUE SHIELD #
NC3324386OtherCIGNA HEALTHCARE PROVIDER
NCP00010140OtherRAILROAD MEDICARE
NC89134J6Medicaid