Provider Demographics
NPI:1053838847
Name:WHITE, CLIFTON JR
Entity Type:Individual
Prefix:
First Name:CLIFTON
Middle Name:
Last Name:WHITE
Suffix:JR
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1361 JAMESTOWNE DR
Mailing Address - Street 2:
Mailing Address - City:SEVERN
Mailing Address - State:MD
Mailing Address - Zip Code:21144-2724
Mailing Address - Country:US
Mailing Address - Phone:301-529-5301
Mailing Address - Fax:240-765-6336
Practice Address - Street 1:1361 JAMESTOWNE DR
Practice Address - Street 2:
Practice Address - City:SEVERN
Practice Address - State:MD
Practice Address - Zip Code:21144-2724
Practice Address - Country:US
Practice Address - Phone:301-529-5301
Practice Address - Fax:240-765-6336
Is Sole Proprietor?:No
Enumeration Date:2017-08-23
Last Update Date:2022-07-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MDW-300-119-009-336172A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes172A00000XOther Service ProvidersDriver