Provider Demographics
NPI:1144226812
Name:WHITE, STEPHEN J (MD)
Entity Type:Individual
Prefix:
First Name:STEPHEN
Middle Name:J
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 1:4601 HERITAGE TRACE PARKWAY
Mailing Address - Street 2:
Mailing Address - City:FORT WORTH
Mailing Address - State:TX
Mailing Address - Zip Code:76244
Mailing Address - Country:US
Mailing Address - Phone:817-431-7985
Mailing Address - Fax:817-431-5031
Practice Address - Street 1:4601 HERITAGE TRACE PARKWAY
Practice Address - Street 2:
Practice Address - City:FORT WORTH
Practice Address - State:TX
Practice Address - Zip Code:76244
Practice Address - Country:US
Practice Address - Phone:817-431-7985
Practice Address - Fax:817-431-5031
Is Sole Proprietor?:Yes
Enumeration Date:2005-06-27
Last Update Date:2018-06-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TXN6768207Y00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Y00000XAllopathic & Osteopathic PhysiciansOtolaryngology
Provider Identifiers
StateIdentifier IDID TypeIssuer
OR022722Medicaid
OR134029Medicare PIN
I05419Medicare UPIN