Provider Demographics
NPI:1700904174
Name:WHITEHOUSE, MYRA JODY (MD)
Entity Type:Individual
Prefix:DR
First Name:MYRA
Middle Name:JODY
Last Name:WHITEHOUSE
Suffix:
Gender:F
Credentials:MD
Other - Prefix:DR
Other - First Name:M.
Other - Middle Name:JODY
Other - Last Name:WHITEHOUSE
Other - Suffix:
Other - Last Name Type:Other Name
Other - Credentials:
Mailing Address - Street 1:6200 WILSHIRE BLVD STE 1010
Mailing Address - Street 2:
Mailing Address - City:LOS ANGELES
Mailing Address - State:CA
Mailing Address - Zip Code:90048-5811
Mailing Address - Country:US
Mailing Address - Phone:424-284-2440
Mailing Address - Fax:
Practice Address - Street 1:6200 WILSHIRE BLVD STE 1010
Practice Address - Street 2:
Practice Address - City:LOS ANGELES
Practice Address - State:CA
Practice Address - Zip Code:90048
Practice Address - Country:US
Practice Address - Phone:424-284-2440
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2007-03-26
Last Update Date:2018-08-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAG1541762084P0800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2084P0800XAllopathic & Osteopathic PhysiciansPsychiatry & NeurologyPsychiatry
Provider Identifiers
StateIdentifier IDID TypeIssuer
NJE58971Medicare UPIN