Provider Demographics
NPI:1104824788
Name:WHITE, EDWARD J (MD, FACS)
Entity Type:Individual
Prefix:DR
First Name:EDWARD
Middle Name:J
Last Name:WHITE
Suffix:
Gender:M
Credentials:MD, FACS
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:PO BOX 789
Mailing Address - Street 2:
Mailing Address - City:LUDLOW
Mailing Address - State:MA
Mailing Address - Zip Code:01056-0789
Mailing Address - Country:US
Mailing Address - Phone:413-509-1000
Mailing Address - Fax:413-509-1003
Practice Address - Street 1:146 HAZARD AVE
Practice Address - Street 2:SUITE 101-B
Practice Address - City:ENFIELD
Practice Address - State:CT
Practice Address - Zip Code:06082-4571
Practice Address - Country:US
Practice Address - Phone:860-749-2318
Practice Address - Fax:860-749-7196
Is Sole Proprietor?:No
Enumeration Date:2005-07-08
Last Update Date:2010-03-31
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CT039210208600000X, 2086X0206X, 2086S0129X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208600000XAllopathic & Osteopathic PhysiciansSurgery
No2086X0206XAllopathic & Osteopathic PhysiciansSurgerySurgical Oncology
No2086S0129XAllopathic & Osteopathic PhysiciansSurgeryVascular Surgery
Provider Identifiers
StateIdentifier IDID TypeIssuer
CT00139210900OtherBLUE CARE FAMILY PLAN
CT611419998OtherFIRST HEALTH
CT611419998OtherNORTHEAST HEALTH DIRECT
CT611419998OtherPIONEER HEALTH CARE
CT001392109Medicaid
CTP2718117OtherOXFORD PROVIDER NUMBER
CT2V2766OtherHEALTH NET
CT611419998OtherCIGNA PROVIDER NUMBER
CT611419998OtherCOMMUNITY HEALTH NETWORK
CT010039210CT01OtherANTHEM BCBS
CT206898OtherPREFERRED ONE
CT2991329OtherAETNA PROVIDER NUMBER
CT611419998OtherPHCS
CT039210OtherCONNECTICARE
CT611419998OtherTRICARE
CT611419998OtherUNITED HEALTHCARE
CTA40558Medicare UPIN
CT02001542Medicare ID - Type Unspecified