Provider Demographics
NPI:1427460526
Name:WHITEHEAD, MITCHELL EUGENE (MD)
Entity type:Individual
Prefix:
First Name:MITCHELL
Middle Name:EUGENE
Last Name:WHITEHEAD
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 1:5100 N 12TH AVE STE 201
Mailing Address - Street 2:
Mailing Address - City:PENSACOLA
Mailing Address - State:FL
Mailing Address - Zip Code:32504-8919
Mailing Address - Country:US
Mailing Address - Phone:850-437-8485
Mailing Address - Fax:
Practice Address - Street 1:5100 N 12TH AVE STE 201
Practice Address - Street 2:
Practice Address - City:PENSACOLA
Practice Address - State:FL
Practice Address - Zip Code:32504
Practice Address - Country:US
Practice Address - Phone:850-437-8485
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2014-05-22
Last Update Date:2020-12-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLTRN19942207Q00000X
FLME125587207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
FL021092300Medicaid