Provider Demographics
NPI:1063455673
Name:WHITE, JEREMY RUSSELL (MD)
Entity Type:Individual
Prefix:
First Name:JEREMY
Middle Name:RUSSELL
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 1:920 STANTON L YOUNG BLVD
Mailing Address - Street 2:ROOM WP 1380
Mailing Address - City:OKLAHOMA CITH
Mailing Address - State:OK
Mailing Address - Zip Code:73104
Mailing Address - Country:US
Mailing Address - Phone:405-271-4426
Mailing Address - Fax:405-271-3461
Practice Address - Street 1:825 NE 10TH ST.
Practice Address - Street 2:SUITE 1300
Practice Address - City:OKLAHOMA CITY
Practice Address - State:OK
Practice Address - Zip Code:73104
Practice Address - Country:US
Practice Address - Phone:405-271-2663
Practice Address - Fax:405-271-6762
Is Sole Proprietor?:No
Enumeration Date:2006-06-13
Last Update Date:2011-04-20
Deactivation Date:
Deactivation Code:
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Provider Licenses
StateLicense IDTaxonomies
WI47872207X00000X
OK26943207X00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207X00000XAllopathic & Osteopathic PhysiciansOrthopaedic Surgery