Provider Demographics
NPI:1184933384
Name:JOHN D. WHITEHEAD
Entity type:Organization
Organization Name:JOHN D. WHITEHEAD
Other - Org Name:<UNAVAIL>
Other - Org Type:
Authorized Official - Title/Position:OWNER/MANAGER
Authorized Official - Prefix:
Authorized Official - First Name:JOHN
Authorized Official - Middle Name:D
Authorized Official - Last Name:WHITEHEAD
Authorized Official - Suffix:
Authorized Official - Credentials:CRT
Authorized Official - Phone:662-834-4600
Mailing Address - Street 1:PO BOX 652
Mailing Address - Street 2:
Mailing Address - City:DURANT
Mailing Address - State:MS
Mailing Address - Zip Code:39063
Mailing Address - Country:US
Mailing Address - Phone:662-834-4600
Mailing Address - Fax:662-834-4606
Practice Address - Street 1:22743 HWY 12
Practice Address - Street 2:
Practice Address - City:LEXINGTON
Practice Address - State:MS
Practice Address - Zip Code:39095
Practice Address - Country:US
Practice Address - Phone:662-834-4600
Practice Address - Fax:662-834-4606
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2010-10-05
Last Update Date:2013-05-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MSRCP0972332BX2000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes332BX2000XSuppliersDurable Medical Equipment & Medical SuppliesOxygen Equipment & Supplies
Provider Identifiers
StateIdentifier IDID TypeIssuer
MS00477052Medicaid
MS6484300001Medicare NSC
6484300001Medicare NSC