Provider Demographics
NPI:1972540508
Name:WHITEHURST, RICHARD G III (DO)
Entity Type:Individual
Prefix:DR
First Name:RICHARD
Middle Name:G
Last Name:WHITEHURST
Suffix:III
Gender:M
Credentials:DO
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:PO BOX 10069
Mailing Address - Street 2:
Mailing Address - City:SAN BERNARDINO
Mailing Address - State:CA
Mailing Address - Zip Code:92423-0069
Mailing Address - Country:US
Mailing Address - Phone:093-354-1889
Mailing Address - Fax:
Practice Address - Street 1:7000 BOULDER AVE
Practice Address - Street 2:
Practice Address - City:HIGHLAND
Practice Address - State:CA
Practice Address - Zip Code:92346-3348
Practice Address - Country:US
Practice Address - Phone:909-862-1191
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2006-06-01
Last Update Date:2022-02-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA020A58490207Q00000X
CA20A5849207P00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207P00000XAllopathic & Osteopathic PhysiciansEmergency Medicine
No207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
CADA748YMedicare PIN
CAF74824Medicare UPIN
CA020A58493Medicare PIN