Provider Demographics
NPI:1235115411
Name:WHITAKER, PHILLIP RAY (MD)
Entity type:Individual
Prefix:DR
First Name:PHILLIP
Middle Name:RAY
Last Name:WHITAKER
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 650865
Mailing Address - Street 2:
Mailing Address - City:DALLAS
Mailing Address - State:TX
Mailing Address - Zip Code:75265-0865
Mailing Address - Country:US
Mailing Address - Phone:972-715-5000
Mailing Address - Fax:972-715-9976
Practice Address - Street 1:6606 LBJ FWY
Practice Address - Street 2:SUITE 200
Practice Address - City:DALLAS
Practice Address - State:TX
Practice Address - Zip Code:75240-6533
Practice Address - Country:US
Practice Address - Phone:972-715-5000
Practice Address - Fax:972-715-9976
Is Sole Proprietor?:No
Enumeration Date:2005-12-19
Last Update Date:2015-11-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TXH4790207L00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207L00000XAllopathic & Osteopathic PhysiciansAnesthesiology
Provider Identifiers
StateIdentifier IDID TypeIssuer
TX128217008Medicaid
TX8EH839OtherBCBS
TXP01446946OtherRR
86840Medicare UPIN
TX128217008Medicaid
TXP01446946OtherRR
TX89109KMedicare PIN
TX89094KMedicare PIN
TX84720KOtherBCBS
TX128217006Medicaid