Provider Demographics
NPI:1356339964
Name:WHITAKER, PAUL MCCOLES (PHD)
Entity type:Individual
Prefix:DR
First Name:PAUL
Middle Name:MCCOLES
Last Name:WHITAKER
Suffix:
Gender:M
Credentials:PHD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:3529 32ND ST
Mailing Address - Street 2:
Mailing Address - City:SAN DIEGO
Mailing Address - State:CA
Mailing Address - Zip Code:92104-4302
Mailing Address - Country:US
Mailing Address - Phone:619-204-2382
Mailing Address - Fax:619-692-0299
Practice Address - Street 1:4420 HOTEL CIRCLE CT
Practice Address - Street 2:SUITE 235
Practice Address - City:SAN DIEGO
Practice Address - State:CA
Practice Address - Zip Code:92108-3411
Practice Address - Country:US
Practice Address - Phone:619-204-2382
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2005-10-07
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAPSY14205103T00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103T00000XBehavioral Health & Social Service ProvidersPsychologist
Provider Identifiers
StateIdentifier IDID TypeIssuer
CACP14205BMedicare ID - Type Unspecified