Provider Demographics
NPI:1912950122
Name:WHITWAM, PAUL R (MD)
Entity Type:Individual
Prefix:DR
First Name:PAUL
Middle Name:R
Last Name:WHITWAM
Suffix:
Gender:M
Credentials:MD
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Mailing Address - Street 1:601 W COUNTRY CLUB RD
Mailing Address - Street 2:SUITE #102
Mailing Address - City:ROSWELL
Mailing Address - State:NM
Mailing Address - Zip Code:88201-5224
Mailing Address - Country:US
Mailing Address - Phone:575-623-3333
Mailing Address - Fax:575-624-4781
Practice Address - Street 1:601 W COUNTRY CLUB RD
Practice Address - Street 2:SUITE #102
Practice Address - City:ROSWELL
Practice Address - State:NM
Practice Address - Zip Code:88201-5224
Practice Address - Country:US
Practice Address - Phone:575-623-3333
Practice Address - Fax:575-624-4781
Is Sole Proprietor?:No
Enumeration Date:2006-05-18
Last Update Date:2014-08-21
Deactivation Date:
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Provider Licenses
StateLicense IDTaxonomies
NM73-226208600000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208600000XAllopathic & Osteopathic PhysiciansSurgery
Provider Identifiers
StateIdentifier IDID TypeIssuer
NM21977364Medicaid
NM345700701Medicare PIN
NM21977364Medicaid