Provider Demographics
NPI:1184914491
Name:WHIDDON, RICHARD EHREN (DO)
Entity type:Individual
Prefix:
First Name:RICHARD
Middle Name:EHREN
Last Name:WHIDDON
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:PO BOX 841656
Mailing Address - Street 2:
Mailing Address - City:DALLAS
Mailing Address - State:TX
Mailing Address - Zip Code:75284-1656
Mailing Address - Country:US
Mailing Address - Phone:903-531-5000
Mailing Address - Fax:
Practice Address - Street 1:800 E DAWSON ST
Practice Address - Street 2:
Practice Address - City:TYLER
Practice Address - State:TX
Practice Address - Zip Code:75701-2036
Practice Address - Country:US
Practice Address - Phone:903-531-5286
Practice Address - Fax:903-531-5061
Is Sole Proprietor?:No
Enumeration Date:2011-04-08
Last Update Date:2015-12-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TXP9135207P00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207P00000XAllopathic & Osteopathic PhysiciansEmergency Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
TX350234603Medicaid
TX350234602Medicaid
TX350234601Medicaid
TX350234604Medicaid
TX427931YS6PMedicare PIN
TX427931YS6VMedicare PIN
TX350234602Medicaid
TX427931YMAFMedicare PIN