Provider Demographics
NPI:1366460990
Name:WHALEN, THOMAS BRIAN (MD)
Entity type:Individual
Prefix:DR
First Name:THOMAS
Middle Name:BRIAN
Last Name:WHALEN
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 1:5120 NW 67TH ST
Mailing Address - Street 2:
Mailing Address - City:GAINESVILLE
Mailing Address - State:FL
Mailing Address - Zip Code:32653-3949
Mailing Address - Country:US
Mailing Address - Phone:352-672-8023
Mailing Address - Fax:
Practice Address - Street 1:3703 SW 13TH ST
Practice Address - Street 2:
Practice Address - City:GAINESVILLE
Practice Address - State:FL
Practice Address - Zip Code:32608-3507
Practice Address - Country:US
Practice Address - Phone:352-672-8023
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2006-07-18
Last Update Date:2015-03-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLME90007208D00000X, 207L00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208D00000XAllopathic & Osteopathic PhysiciansGeneral Practice
No207L00000XAllopathic & Osteopathic PhysiciansAnesthesiology
Provider Identifiers
StateIdentifier IDID TypeIssuer
FL269502200Medicaid
E04359Medicare UPIN
E04359Medicare UPIN