Provider Demographics
NPI:1114997640
Name:WHITE, MARK TIMOTHY (MD)
Entity Type:Individual
Prefix:DR
First Name:MARK
Middle Name:TIMOTHY
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 1:1338 HIGHWAY 14
Mailing Address - Street 2:
Mailing Address - City:SIMPSONVILLE
Mailing Address - State:SC
Mailing Address - Zip Code:29681-5637
Mailing Address - Country:US
Mailing Address - Phone:864-297-7091
Mailing Address - Fax:
Practice Address - Street 1:1338 HIGHWAY 14
Practice Address - Street 2:
Practice Address - City:SIMPSONVILLE
Practice Address - State:SC
Practice Address - Zip Code:29681-5637
Practice Address - Country:US
Practice Address - Phone:864-297-7091
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2006-01-26
Last Update Date:2014-10-30
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
SC15006207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
SCGP2352Medicaid
SCGP2352Medicaid
6178Medicare ID - Type Unspecified