Provider Demographics
NPI:1922513522
Name:WHITAKER, SAMMY L
Entity Type:Individual
Prefix:
First Name:SAMMY
Middle Name:L
Last Name:WHITAKER
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 1:719 WHEELHOUSE DR
Mailing Address - Street 2:
Mailing Address - City:STAFFORD
Mailing Address - State:TX
Mailing Address - Zip Code:77477-5829
Mailing Address - Country:US
Mailing Address - Phone:832-641-0240
Mailing Address - Fax:281-208-0247
Practice Address - Street 1:719 WHEELHOUSE DR
Practice Address - Street 2:
Practice Address - City:STAFFORD
Practice Address - State:TX
Practice Address - Zip Code:77477-5829
Practice Address - Country:US
Practice Address - Phone:832-641-0240
Practice Address - Fax:281-208-0247
Is Sole Proprietor?:Yes
Enumeration Date:2017-12-05
Last Update Date:2017-12-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes172A00000XOther Service ProvidersDriver
Provider Identifiers
StateIdentifier IDID TypeIssuer
TX75-3225134Medicaid