Provider Demographics
NPI:1205829298
Name:WHITE, BRADLEY A (MD)
Entity Type:Individual
Prefix:
First Name:BRADLEY
Middle Name:A
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 1:1903 E BEEBE CAPPS BLVD
Mailing Address - Street 2:
Mailing Address - City:SEARCY
Mailing Address - State:AR
Mailing Address - Zip Code:72143
Mailing Address - Country:US
Mailing Address - Phone:501-279-3838
Mailing Address - Fax:501-279-1212
Practice Address - Street 1:1903 E BEEBE CAPPS BLVD
Practice Address - Street 2:
Practice Address - City:SEARCY
Practice Address - State:AR
Practice Address - Zip Code:72143-5012
Practice Address - Country:US
Practice Address - Phone:501-279-3838
Practice Address - Fax:501-279-1212
Is Sole Proprietor?:Yes
Enumeration Date:2005-08-25
Last Update Date:2007-07-08
Deactivation Date:2006-03-27
Deactivation Code:
Reactivation Date:2006-04-12
Provider Licenses
StateLicense IDTaxonomies
ARE1140207N00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207N00000XAllopathic & Osteopathic PhysiciansDermatology
Provider Identifiers
StateIdentifier IDID TypeIssuer
ARG85130Medicare UPIN
AR5L048Medicare ID - Type Unspecified