Provider Demographics
NPI:1245291590
Name:WHITEHEAD, DANIEL W JR (MD)
Entity type:Individual
Prefix:DR
First Name:DANIEL
Middle Name:W
Last Name:WHITEHEAD
Suffix:JR
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:243 DUNN RD
Mailing Address - Street 2:
Mailing Address - City:FLORISSANT
Mailing Address - State:MO
Mailing Address - Zip Code:63031-7928
Mailing Address - Country:US
Mailing Address - Phone:314-831-5000
Mailing Address - Fax:314-831-5110
Practice Address - Street 1:243 DUNN RD
Practice Address - Street 2:
Practice Address - City:FLORISSANT
Practice Address - State:MO
Practice Address - Zip Code:63031-7928
Practice Address - Country:US
Practice Address - Phone:314-831-5000
Practice Address - Fax:314-831-5110
Is Sole Proprietor?:No
Enumeration Date:2006-03-28
Last Update Date:2014-12-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MOR8B85207R00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207R00000XAllopathic & Osteopathic PhysiciansInternal Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
MO110163848OtherRAILROAD MEDICARE
MO967285280Medicare PIN
MO110163848OtherRAILROAD MEDICARE