Provider Demographics
NPI:1316944622
Name:WHITBECK, M. GORDON JR (MD)
Entity type:Individual
Prefix:
First Name:M.
Middle Name:GORDON
Last Name:WHITBECK
Suffix:JR
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 1:100 KINGS HWY S
Mailing Address - Street 2:
Mailing Address - City:ROCHESTER
Mailing Address - State:NY
Mailing Address - Zip Code:14617-5504
Mailing Address - Country:US
Mailing Address - Phone:585-922-0553
Mailing Address - Fax:585-922-0496
Practice Address - Street 1:2619 CULVER RD
Practice Address - Street 2:
Practice Address - City:ROCHESTER
Practice Address - State:NY
Practice Address - Zip Code:14609-1738
Practice Address - Country:US
Practice Address - Phone:585-342-2410
Practice Address - Fax:585-342-9141
Is Sole Proprietor?:No
Enumeration Date:2005-06-30
Last Update Date:2021-05-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY167261207X00000X, 207XS0117X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207XS0117XAllopathic & Osteopathic PhysiciansOrthopaedic SurgeryOrthopaedic Surgery of the Spine
No207X00000XAllopathic & Osteopathic PhysiciansOrthopaedic Surgery
Provider Identifiers
StateIdentifier IDID TypeIssuer
NY01422691Medicaid
F34849Medicare UPIN
BA0623Medicare PIN
NY01422691Medicaid