Provider Demographics
NPI:1184749517
Name:WHITWORTH, MICHAEL WESLEY (DO)
Entity type:Individual
Prefix:DR
First Name:MICHAEL
Middle Name:WESLEY
Last Name:WHITWORTH
Suffix:
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 1:1500 EUREKA RD
Mailing Address - Street 2:
Mailing Address - City:WYANDOTTE
Mailing Address - State:MI
Mailing Address - Zip Code:48192-6103
Mailing Address - Country:US
Mailing Address - Phone:734-282-2500
Mailing Address - Fax:734-282-6397
Practice Address - Street 1:1500 EUREKA RD
Practice Address - Street 2:
Practice Address - City:WYANDOTTE
Practice Address - State:MI
Practice Address - Zip Code:48192-6103
Practice Address - Country:US
Practice Address - Phone:734-282-2500
Practice Address - Fax:734-282-6397
Is Sole Proprietor?:Yes
Enumeration Date:2007-03-21
Last Update Date:2014-01-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI5315028187207ND0101X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207ND0101XAllopathic & Osteopathic PhysiciansDermatologyMOHS-Micrographic Surgery
Provider Identifiers
StateIdentifier IDID TypeIssuer
MIP45390013Medicare PIN