Provider Demographics
NPI:1871752428
Name:WHITEHEAD, TIMOTHY (MD)
Entity type:Individual
Prefix:
First Name:TIMOTHY
Middle Name:
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 1:111 OAKWOOD RD
Mailing Address - Street 2:
Mailing Address - City:EAST PEORIA
Mailing Address - State:IL
Mailing Address - Zip Code:61611-1853
Mailing Address - Country:US
Mailing Address - Phone:309-740-4272
Mailing Address - Fax:
Practice Address - Street 1:530 NE GLEN OAK AVE
Practice Address - Street 2:
Practice Address - City:PEORIA
Practice Address - State:IL
Practice Address - Zip Code:61637-5429
Practice Address - Country:US
Practice Address - Phone:309-655-2000
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2008-06-07
Last Update Date:2023-10-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OH35.1238222085R0202X, 2085R0204X
WI822522085R0204X
IL036-1329852085R0204X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2085R0204XAllopathic & Osteopathic PhysiciansRadiologyVascular & Interventional Radiology
No2085R0202XAllopathic & Osteopathic PhysiciansRadiologyDiagnostic Radiology
Provider Identifiers
StateIdentifier IDID TypeIssuer
OH0104941Medicaid
OH35.123822OtherLICENSE
OH35.123822OtherLICENSE