Provider Demographics
NPI:1013197565
Name:MARK W WHITE MD,LLC
Entity Type:Organization
Organization Name:MARK W WHITE MD,LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:DOCTOR
Authorized Official - Prefix:DR
Authorized Official - First Name:MARK
Authorized Official - Middle Name:WILLIAM
Authorized Official - Last Name:WHITE
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:386-274-0250
Mailing Address - Street 1:1890 LPGA BLVD
Mailing Address - Street 2:STE 250
Mailing Address - City:DAYTONA BEACH
Mailing Address - State:FL
Mailing Address - Zip Code:32117-7131
Mailing Address - Country:US
Mailing Address - Phone:386-274-0250
Mailing Address - Fax:386-274-0269
Practice Address - Street 1:1890 LPGA BLVD
Practice Address - Street 2:SUITE 250
Practice Address - City:DAYTONA BEACH
Practice Address - State:FL
Practice Address - Zip Code:32117-7130
Practice Address - Country:US
Practice Address - Phone:386-274-0250
Practice Address - Fax:386-274-0269
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-11-13
Last Update Date:2007-11-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLME75474174400000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes174400000XOther Service ProvidersSpecialistGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
FLH40009Medicare UPIN
FLK6492Medicare PIN