Provider Demographics
NPI:1053311142
Name:WHITE, JOHN MICHAEL (DPM)
Entity Type:Individual
Prefix:DR
First Name:JOHN
Middle Name:MICHAEL
Last Name:WHITE
Suffix:
Gender:M
Credentials:DPM
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 347
Mailing Address - Street 2:
Mailing Address - City:TEXARKANA
Mailing Address - State:TX
Mailing Address - Zip Code:75504-0347
Mailing Address - Country:US
Mailing Address - Phone:903-792-2121
Mailing Address - Fax:903-793-6444
Practice Address - Street 1:4416 ELIZABETH ST
Practice Address - Street 2:
Practice Address - City:TEXARKANA
Practice Address - State:TX
Practice Address - Zip Code:75503-2902
Practice Address - Country:US
Practice Address - Phone:903-792-2121
Practice Address - Fax:903-793-6444
Is Sole Proprietor?:Yes
Enumeration Date:2005-07-29
Last Update Date:2012-05-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TX1221213E00000X
OK181213E00000X
AR134213E00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes213E00000XPodiatric Medicine & Surgery Service ProvidersPodiatrist
Provider Identifiers
StateIdentifier IDID TypeIssuer
TX0187395-01Medicaid
AR154960716OtherMEDICAID DME
TX480027525OtherRAILROAD MEDICARE
AR128645717Medicaid
TX0645790001OtherPALMETTO
OK100779580AMedicaid
AR480015333OtherRAILROAD MEDICARE
TX480027525OtherRAILROAD MEDICARE
AR480015333OtherRAILROAD MEDICARE
TX00J23PMedicare PIN