Basic Information
Provider Information
NPI: 1003014762
EntityType: 1
ReplacementNPI:  
OrganizationName:  
LastName: WHARTON
FirstName: JOSHUA
MiddleName: BLAKE
NamePrefix: DR.
NameSuffix:  
Credential: M.D.
OtherOrganizationName:  
OtherOrganizationType:  
OtherLastName:  
OtherFirstName:  
OtherMiddleName:  
OtherNamePrefix:  
OtherNameSuffix:  
OtherCredential:  
OtherLastNameType:  
Mailing Information
Address1: 2307 HOMER CLAYTON DR
Address2:  
City: GUNTERSVILLE
State: AL
PostalCode: 359762205
CountryCode: US
TelephoneNumber: 2565718770
FaxNumber:  
Practice Location
Address1: 2307 HOMER CLAYTON DR
Address2:  
City: GUNTERSVILLE
State: AL
PostalCode: 359762205
CountryCode: US
TelephoneNumber: 2565718770
FaxNumber:  
Other Information
ProviderEnumerationDate: 07/04/2007
LastUpdateDate: 02/02/2012
NPIDeactivationReasonCode:  
NPIDeactivationDate:  
NPIReactivationDate:  
ProviderGenderCode: M
AuthorizedOfficialLastName:  
AuthorizedOfficialFirstName:  
AuthorizedOfficialMiddleName:  
AuthorizedOfficialTitleorPosition:  
AuthorizedOfficialTelephone:  
IsSoleProprietor: N
IsOrganizationSubpart:  
ParentOrganizationLBN:  
AuthorizedOfficialNamePrefix:  
AuthorizedOfficialNameSuffix:  
AuthorizedOfficialCredential:  
NPICertificationDate:  

Taxonomy Information
TaxonomyLicenseStateSwitchTaxonomyGroupTaxonomyTypeTaxonomyClassSubSpecialty
207N00000X002457GAY Allopathic & Osteopathic PhysiciansDermatology 

No ID Information.


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