Provider Demographics
NPI:1770560989
Name:WHITTEN, THOMAS M (MD)
Entity type:Individual
Prefix:
First Name:THOMAS
Middle Name:M
Last Name:WHITTEN
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 1:1060 S MAIN ST STE 2
Mailing Address - Street 2:
Mailing Address - City:TIPTON
Mailing Address - State:IN
Mailing Address - Zip Code:46072-8327
Mailing Address - Country:US
Mailing Address - Phone:765-675-9889
Mailing Address - Fax:888-544-9037
Practice Address - Street 1:1060 S MAIN ST STE 2
Practice Address - Street 2:
Practice Address - City:TIPTON
Practice Address - State:IN
Practice Address - Zip Code:46072-8327
Practice Address - Country:US
Practice Address - Phone:765-675-9889
Practice Address - Fax:888-544-9037
Is Sole Proprietor?:No
Enumeration Date:2005-12-29
Last Update Date:2016-01-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IN01055526208600000X
IN01055526A202K00000X, 2086S0129X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208600000XAllopathic & Osteopathic PhysiciansSurgery
No202K00000XAllopathic & Osteopathic PhysiciansPhlebology
No2086S0129XAllopathic & Osteopathic PhysiciansSurgeryVascular Surgery
Provider Identifiers
StateIdentifier IDID TypeIssuer
IN000000320783OtherANTHEM
IN200356650Medicaid
INQ0089831OtherSHO
INP00131841Medicare PIN
INQ0089831OtherSHO