Provider Demographics
NPI:1902369523
Name:WHITWORTH, MARK
Entity Type:Individual
Prefix:
First Name:MARK
Middle Name:
Last Name:WHITWORTH
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 1:30 RACQUET CLUB PKWY
Mailing Address - Street 2:
Mailing Address - City:PELHAM
Mailing Address - State:AL
Mailing Address - Zip Code:35124-6185
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:30 RACQUET CLUB PKWY STE A
Practice Address - Street 2:
Practice Address - City:PELHAM
Practice Address - State:AL
Practice Address - Zip Code:35124-6185
Practice Address - Country:US
Practice Address - Phone:205-971-1601
Practice Address - Fax:205-971-1620
Is Sole Proprietor?:Yes
Enumeration Date:2019-04-10
Last Update Date:2023-02-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
390200000X
AL43608207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
No390200000XStudent, Health CareStudent in an Organized Health Care Education/Training Program