Provider Demographics
NPI:1063453223
Name:WHITE, JOHN B (MD)
Entity Type:Individual
Prefix:
First Name:JOHN
Middle Name:B
Last Name:WHITE
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
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Other - Credentials:
Mailing Address - Street 1:PO BOX 140156
Mailing Address - Street 2:
Mailing Address - City:BROKEN ARROW
Mailing Address - State:OK
Mailing Address - Zip Code:74014
Mailing Address - Country:US
Mailing Address - Phone:918-357-5859
Mailing Address - Fax:918-357-5859
Practice Address - Street 1:1620 E 12TH ST
Practice Address - Street 2:
Practice Address - City:TULSA
Practice Address - State:OK
Practice Address - Zip Code:74120-5407
Practice Address - Country:US
Practice Address - Phone:918-357-5859
Practice Address - Fax:918-357-5859
Is Sole Proprietor?:No
Enumeration Date:2006-06-09
Last Update Date:2013-01-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OK163152084P0800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2084P0800XAllopathic & Osteopathic PhysiciansPsychiatry & NeurologyPsychiatry
Provider Identifiers
StateIdentifier IDID TypeIssuer
OK100200630AMedicaid
OK800522425OtherMEDICARE GRP#
OK800522425OtherMEDICARE GRP#
D42923Medicare UPIN