Provider Demographics
NPI:1134104706
Name:WHITE, MARK A (MD)
Entity Type:Individual
Prefix:DR
First Name:MARK
Middle Name:A
Last Name:WHITE
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
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Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:3433 AGLER RD STE 1100
Mailing Address - Street 2:
Mailing Address - City:COLUMBUS
Mailing Address - State:OH
Mailing Address - Zip Code:43219-3390
Mailing Address - Country:US
Mailing Address - Phone:614-453-1065
Mailing Address - Fax:614-453-1078
Practice Address - Street 1:112 JEFFERSON AVE
Practice Address - Street 2:SUITE 201
Practice Address - City:COLUMBUS
Practice Address - State:OH
Practice Address - Zip Code:43215-1702
Practice Address - Country:US
Practice Address - Phone:614-453-1065
Practice Address - Fax:614-453-1078
Is Sole Proprietor?:No
Enumeration Date:2005-12-07
Last Update Date:2021-09-30
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OH35072866207R00000X
OH35-07-2866207R00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207R00000XAllopathic & Osteopathic PhysiciansInternal Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
OH2138485Medicaid
OH2138485Medicaid
OHWH0847922Medicare ID - Type Unspecified