Provider Demographics
NPI:1962512525
Name:WHITEHEAD, RAYMOND Y (MD)
Entity type:Individual
Prefix:
First Name:RAYMOND
Middle Name:Y
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 1:415 S 28TH AVE
Mailing Address - Street 2:
Mailing Address - City:HATTIESBURG
Mailing Address - State:MS
Mailing Address - Zip Code:39401-7246
Mailing Address - Country:US
Mailing Address - Phone:601-268-5630
Mailing Address - Fax:601-579-5240
Practice Address - Street 1:103 MEDICAL PARK FL 2
Practice Address - Street 2:
Practice Address - City:HATTIESBURG
Practice Address - State:MS
Practice Address - Zip Code:39401-9042
Practice Address - Country:US
Practice Address - Phone:601-268-5630
Practice Address - Fax:601-579-3285
Is Sole Proprietor?:No
Enumeration Date:2006-08-30
Last Update Date:2024-05-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MS17154207X00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207X00000XAllopathic & Osteopathic PhysiciansOrthopaedic Surgery
Provider Identifiers
StateIdentifier IDID TypeIssuer
MS00123887Medicaid
MS1559341OtherAMERICAN ADMIN GROUP
LA1595152Medicaid
MS200040877OtherRAILROAD MEDICARE
LA1595152Medicaid
MS200000358Medicare PIN