Provider Demographics
NPI:1134352867
Name:WHITESIDE, DANIELA M (MD)
Entity type:Individual
Prefix:MRS
First Name:DANIELA
Middle Name:M
Last Name:WHITESIDE
Suffix:
Gender:F
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:19208 BETTY STOUGH RD
Mailing Address - Street 2:
Mailing Address - City:CORNELIUS
Mailing Address - State:NC
Mailing Address - Zip Code:28031
Mailing Address - Country:US
Mailing Address - Phone:704-728-9002
Mailing Address - Fax:
Practice Address - Street 1:19208 BETTY STOUGH RD
Practice Address - Street 2:
Practice Address - City:CORNELIUS
Practice Address - State:NC
Practice Address - Zip Code:28031
Practice Address - Country:US
Practice Address - Phone:704-728-9002
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2009-08-28
Last Update Date:2020-03-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NC2005-01237207W00000X, 208D00000X
SC23928207W00000X, 208D00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207W00000XAllopathic & Osteopathic PhysiciansOphthalmology
No208D00000XAllopathic & Osteopathic PhysiciansGeneral Practice
Provider Identifiers
StateIdentifier IDID TypeIssuer
SCAA77322326OtherMEDICARE PTAN
SCN01237Medicaid