Provider Demographics
NPI:1023017167
Name:WHITE, JAY W (DO)
Entity Type:Individual
Prefix:
First Name:JAY
Middle Name:W
Last Name:WHITE
Suffix:
Gender:M
Credentials:DO
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2820 MOUNT RUSHMORE RD
Mailing Address - Street 2:
Mailing Address - City:RAPID CITY
Mailing Address - State:SD
Mailing Address - Zip Code:57701-5462
Mailing Address - Country:US
Mailing Address - Phone:605-342-3280
Mailing Address - Fax:605-721-8458
Practice Address - Street 1:101 E MINNESOTA ST
Practice Address - Street 2:SUITE 210
Practice Address - City:RAPID CITY
Practice Address - State:SD
Practice Address - Zip Code:57701-7756
Practice Address - Country:US
Practice Address - Phone:605-342-3280
Practice Address - Fax:605-721-8458
Is Sole Proprietor?:No
Enumeration Date:2005-07-20
Last Update Date:2012-05-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OH34007897207YX0905X
MI5101013470207YX0905X
SD7612207YX0905X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207YX0905XAllopathic & Osteopathic PhysiciansOtolaryngologyOtolaryngology/Facial Plastic Surgery
Provider Identifiers
StateIdentifier IDID TypeIssuer
OH2338947Medicaid
SD6632340Medicaid
OH2338947Medicaid
SD6632340Medicaid
SDS103727Medicare PIN