Provider Demographics
NPI:1053335828
Name:WHITLOCK, RICHARD RALSTON JR (MD)
Entity type:Individual
Prefix:
First Name:RICHARD
Middle Name:RALSTON
Last Name:WHITLOCK
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 1:1348 WALTON WAY
Mailing Address - Street 2:SUITE 5100
Mailing Address - City:AUGUSTA
Mailing Address - State:GA
Mailing Address - Zip Code:30901-5104
Mailing Address - Country:US
Mailing Address - Phone:706-724-8611
Mailing Address - Fax:706-724-6202
Practice Address - Street 1:1348 WALTON WAY
Practice Address - Street 2:SUITE 5100
Practice Address - City:AUGUSTA
Practice Address - State:GA
Practice Address - Zip Code:30901-5104
Practice Address - Country:US
Practice Address - Phone:706-724-8611
Practice Address - Fax:706-724-6202
Is Sole Proprietor?:No
Enumeration Date:2006-07-26
Last Update Date:2019-02-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GA020623207RC0000X
SC7340207RC0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207RC0000XAllopathic & Osteopathic PhysiciansInternal MedicineCardiovascular Disease
Provider Identifiers
StateIdentifier IDID TypeIssuer
SCG20623Medicaid
GA00179077DMedicaid
GA1585885-004OtherCIGNA
4134155OtherAETNA PPO
GA595429OtherBCBS
897824OtherAETNA HMO
GA1585885-004OtherCIGNA
GA00179077DMedicaid
GA1585885-004OtherCIGNA
406063860Medicare ID - Type UnspecifiedRAILROAD