Provider Demographics
NPI:1104854389
Name:WHITE, JEREMY C (MD)
Entity Type:Individual
Prefix:
First Name:JEREMY
Middle Name:C
Last Name:WHITE
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:725 TAYOPA CT
Mailing Address - Street 2:
Mailing Address - City:EL PASO
Mailing Address - State:TX
Mailing Address - Zip Code:79932-2539
Mailing Address - Country:US
Mailing Address - Phone:832-326-2666
Mailing Address - Fax:
Practice Address - Street 1:4800 ALBERTA
Practice Address - Street 2:
Practice Address - City:EL PASO
Practice Address - State:TX
Practice Address - Zip Code:79905
Practice Address - Country:US
Practice Address - Phone:915-545-6720
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2006-06-28
Last Update Date:2012-10-30
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TXK8570207PE0004X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207PE0004XAllopathic & Osteopathic PhysiciansEmergency MedicineEmergency Medical Services
Provider Identifiers
StateIdentifier IDID TypeIssuer
G91982Medicare UPIN