Provider Demographics
NPI:1972539302
Name:WHITLOCK-MORALES, AUTUMN BETH (MD)
Entity type:Individual
Prefix:DR
First Name:AUTUMN
Middle Name:BETH
Last Name:WHITLOCK-MORALES
Suffix:
Gender:F
Credentials:MD
Other - Prefix:
Other - First Name:AUTUMN
Other - Middle Name:BETH
Other - Last Name:WHITLOCK-MORALES
Other - Suffix:
Other - Last Name Type:Professional Name
Other - Credentials:MD
Mailing Address - Street 1:2900 SAINT MICHAEL DR STE 401
Mailing Address - Street 2:
Mailing Address - City:TEXARKANA
Mailing Address - State:TX
Mailing Address - Zip Code:75503-5211
Mailing Address - Country:US
Mailing Address - Phone:903-614-5372
Mailing Address - Fax:903-614-5343
Practice Address - Street 1:1311 E GENERAL CAVAZOS BLVD STE 201
Practice Address - Street 2:
Practice Address - City:KINGSVILLE
Practice Address - State:TX
Practice Address - Zip Code:78363-7123
Practice Address - Country:US
Practice Address - Phone:361-595-2223
Practice Address - Fax:361-595-9687
Is Sole Proprietor?:No
Enumeration Date:2006-06-25
Last Update Date:2021-04-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WV22119207R00000X
IA39466207R00000X, 208000000X
TXR9558208000000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208000000XAllopathic & Osteopathic PhysiciansPediatrics
No207R00000XAllopathic & Osteopathic PhysiciansInternal Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
TXPENDINGMedicaid
WV3810005860Medicaid
IAI10723011Medicare Oscar/Certification
WVMO7357621Medicare PIN