Provider Demographics
NPI:1427478452
Name:WHETSTONE, ADDISON G (MD)
Entity type:Individual
Prefix:
First Name:ADDISON
Middle Name:G
Last Name:WHETSTONE
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:PO BOX 841656
Mailing Address - Street 2:
Mailing Address - City:DALLAS
Mailing Address - State:TX
Mailing Address - Zip Code:75284-1656
Mailing Address - Country:US
Mailing Address - Phone:903-531-5000
Mailing Address - Fax:
Practice Address - Street 1:800 E DAWSON ST
Practice Address - Street 2:
Practice Address - City:TYLER
Practice Address - State:TX
Practice Address - Zip Code:75701-2036
Practice Address - Country:US
Practice Address - Phone:903-606-4262
Practice Address - Fax:903-606-0597
Is Sole Proprietor?:Yes
Enumeration Date:2014-04-17
Last Update Date:2022-07-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
390200000X
TXR0674207P00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207P00000XAllopathic & Osteopathic PhysiciansEmergency Medicine
No390200000XStudent, Health CareStudent in an Organized Health Care Education/Training Program
Provider Identifiers
StateIdentifier IDID TypeIssuer
TX75-0818167-015OtherTRICARE
TX8HE341OtherBCBS
TX75-0818167-051OtherTRICARE
TX75-1976930-005OtherTRICARE
TX581281YS6POtherMEDICARE
TX75-0818167-048OtherTRICARE
TXP01877171OtherMEDICARE RAIL ROAD
TX75-0818167-044OtherTRICARE
TX374213202Medicaid
TX8GY068OtherBCBS
TX374213201Medicaid
TX581281YS6VOtherMEDICARE
TXP01876971OtherMEDICARE RAIL ROAD