Provider Demographics
NPI:1700057106
Name:WHITEHEAD, KRISTOPHER WAYNE (MD)
Entity Type:Individual
Prefix:
First Name:KRISTOPHER
Middle Name:WAYNE
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:PO BOX 829
Mailing Address - Street 2:
Mailing Address - City:TUPELO
Mailing Address - State:MS
Mailing Address - Zip Code:38802-0829
Mailing Address - Country:US
Mailing Address - Phone:662-377-7100
Mailing Address - Fax:662-377-7115
Practice Address - Street 1:499 GLOSTER CREEK VLG
Practice Address - Street 2:SUITE A1
Practice Address - City:TUPELO
Practice Address - State:MS
Practice Address - Zip Code:38801-4600
Practice Address - Country:US
Practice Address - Phone:662-377-7100
Practice Address - Fax:662-377-7115
Is Sole Proprietor?:No
Enumeration Date:2008-03-13
Last Update Date:2016-07-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MS21047208800000X
FLME96599208800000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208800000XAllopathic & Osteopathic PhysiciansUrology