Provider Demographics
NPI:1255383675
Name:WHITTEMORE, DOUGLAS M (MD)
Entity type:Individual
Prefix:DR
First Name:DOUGLAS
Middle Name:M
Last Name:WHITTEMORE
Suffix:
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 1:345 HANKS HILL RD
Mailing Address - Street 2:
Mailing Address - City:STORRS MANSFIELD
Mailing Address - State:CT
Mailing Address - Zip Code:06268-2349
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:345 HANKS HILL RD
Practice Address - Street 2:
Practice Address - City:STORRS MANSFIELD
Practice Address - State:CT
Practice Address - Zip Code:06268-2349
Practice Address - Country:US
Practice Address - Phone:860-420-9299
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2006-05-16
Last Update Date:2011-01-24
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CT023672174400000X
MA238240174400000X, 208800000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208800000XAllopathic & Osteopathic PhysiciansUrology
No174400000XOther Service ProvidersSpecialist
Provider Identifiers
StateIdentifier IDID TypeIssuer
MA9771476Medicaid
MAM20928OtherGROUP MEDICARE
MA9771476Medicaid