Provider Demographics
NPI:1871603688
Name:WHITEHEAD, WILLIAM A (MD)
Entity type:Individual
Prefix:
First Name:WILLIAM
Middle Name:A
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:601-268-5660
Mailing Address - Fax:601-579-5240
Practice Address - Street 1:415 S 28TH AVE
Practice Address - Street 2:
Practice Address - City:HATTIESBURG
Practice Address - State:MS
Practice Address - Zip Code:39401-7246
Practice Address - Country:US
Practice Address - Phone:601-268-5660
Practice Address - Fax:601-268-5759
Is Sole Proprietor?:No
Enumeration Date:2006-08-30
Last Update Date:2016-08-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MS09358208600000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208600000XAllopathic & Osteopathic PhysiciansSurgery
Provider Identifiers
StateIdentifier IDID TypeIssuer
MS1558990OtherAMERICAN ADMIN GROUP
MS00019870Medicaid
MS021948708OtherRAILROAD MEDICARE
LA1595454Medicaid
MS1558990OtherAMERICAN ADMIN GROUP
D00957Medicare UPIN