Provider Demographics
NPI:1063404002
Name:WHITTAKER, THOMAS L (MD)
Entity type:Individual
Prefix:
First Name:THOMAS
Middle Name:L
Last Name:WHITTAKER
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 1:6330 E 75TH ST
Mailing Address - Street 2:
Mailing Address - City:INDIANAPOLIS
Mailing Address - State:IN
Mailing Address - Zip Code:46250-2777
Mailing Address - Country:US
Mailing Address - Phone:317-594-6900
Mailing Address - Fax:317-594-6911
Practice Address - Street 1:ONE MEMORIAL SQ
Practice Address - Street 2:STE 50
Practice Address - City:GREENFIELD
Practice Address - State:IN
Practice Address - Zip Code:46140-1357
Practice Address - Country:US
Practice Address - Phone:317-467-7100
Practice Address - Fax:317-467-0209
Is Sole Proprietor?:No
Enumeration Date:2005-08-16
Last Update Date:2012-08-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IN01041624207RX0202X, 207RH0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207RX0202XAllopathic & Osteopathic PhysiciansInternal MedicineMedical Oncology
No207RH0000XAllopathic & Osteopathic PhysiciansInternal MedicineHematology
Provider Identifiers
StateIdentifier IDID TypeIssuer
IN900000282OtherRAILROAD MEDICARE PIN
IN100323710Medicaid
INP01055080OtherRAILROAD MEDICARE PIN
IN100323710Medicaid
065910JMedicare ID - Type Unspecified
IN100323710Medicaid
INM400056821Medicare PIN