Provider Demographics
NPI:1093778011
Name:WHITE, DIANE (MD)
Entity Type:Individual
Prefix:DR
First Name:DIANE
Middle Name:
Last Name:WHITE
Suffix:
Gender:F
Credentials:MD
Other - Prefix:DR
Other - First Name:DIANE
Other - Middle Name:
Other - Last Name:WHITE
Other - Suffix:
Other - Last Name Type:Professional Name
Other - Credentials:MD
Mailing Address - Street 1:2914 N ELM ST # 183
Mailing Address - Street 2:
Mailing Address - City:LUMBERTON
Mailing Address - State:NC
Mailing Address - Zip Code:28358-2981
Mailing Address - Country:US
Mailing Address - Phone:310-780-3444
Mailing Address - Fax:
Practice Address - Street 1:603 PECAN LANE
Practice Address - Street 2:
Practice Address - City:WHITEVILLE
Practice Address - State:NC
Practice Address - Zip Code:28472-2835
Practice Address - Country:US
Practice Address - Phone:310-780-3444
Practice Address - Fax:310-780-3444
Is Sole Proprietor?:Yes
Enumeration Date:2006-04-10
Last Update Date:2018-03-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NCBW1823221207R00000X, 207RA0401X
NCBW1823221X2084P0802X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207RA0401XAllopathic & Osteopathic PhysiciansInternal MedicineAddiction Medicine
No207R00000XAllopathic & Osteopathic PhysiciansInternal Medicine
No2084P0802XAllopathic & Osteopathic PhysiciansPsychiatry & NeurologyAddiction Psychiatry
Provider Identifiers
StateIdentifier IDID TypeIssuer
NC1093778011Medicaid
NC2204758AMedicare PIN