Provider Demographics
NPI:1548295421
Name:WHITLOCK, MICHAEL SHANE (MD)
Entity type:Individual
Prefix:DR
First Name:MICHAEL
Middle Name:SHANE
Last Name:WHITLOCK
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 2008
Mailing Address - Street 2:
Mailing Address - City:MOUNTAIN HOME
Mailing Address - State:AR
Mailing Address - Zip Code:72654-2008
Mailing Address - Country:US
Mailing Address - Phone:870-425-6322
Mailing Address - Fax:870-424-5859
Practice Address - Street 1:624 HOSPITAL DR. RAD. DEPT.
Practice Address - Street 2:
Practice Address - City:MOUNTAIN HOME
Practice Address - State:AR
Practice Address - Zip Code:72653-2955
Practice Address - Country:US
Practice Address - Phone:870-425-6322
Practice Address - Fax:870-424-5859
Is Sole Proprietor?:Yes
Enumeration Date:2006-07-11
Last Update Date:2017-01-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
ARE37462085R0202X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2085R0202XAllopathic & Osteopathic PhysiciansRadiologyDiagnostic Radiology
Provider Identifiers
StateIdentifier IDID TypeIssuer
AR165369001Medicaid
AR5N941Medicare PIN
WAI55188Medicare UPIN
WA8860734Medicare ID - Type UnspecifiedUWP