Provider Demographics
NPI:1063646230
Name:WHITE, JAMES MICHAEL (IDMT)
Entity Type:Individual
Prefix:MR
First Name:JAMES
Middle Name:MICHAEL
Last Name:WHITE
Suffix:
Gender:M
Credentials:IDMT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:3278 MITCHELL BLVD
Mailing Address - Street 2:BLDG. 900
Mailing Address - City:MOODY AFB
Mailing Address - State:GA
Mailing Address - Zip Code:31699-1500
Mailing Address - Country:US
Mailing Address - Phone:228-257-8214
Mailing Address - Fax:
Practice Address - Street 1:3278 MITHELL BLVD
Practice Address - Street 2:BLDG. 900
Practice Address - City:MOODY AFB
Practice Address - State:GA
Practice Address - Zip Code:31699
Practice Address - Country:US
Practice Address - Phone:229-257-8214
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2009-05-04
Last Update Date:2014-12-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1710I1003XOther Service ProvidersMilitary Health Care ProviderIndependent Duty Medical Technicians