Provider Demographics
NPI:1215001144
Name:WHITE, HORACE ROGER (MD)
Entity Type:Individual
Prefix:
First Name:HORACE
Middle Name:ROGER
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 1:1660 CAVAN DR SW
Mailing Address - Street 2:
Mailing Address - City:MARIETTA
Mailing Address - State:GA
Mailing Address - Zip Code:30064-2942
Mailing Address - Country:US
Mailing Address - Phone:770-424-1782
Mailing Address - Fax:
Practice Address - Street 1:49 S MARIETTA PKWY SW
Practice Address - Street 2:#C
Practice Address - City:MARIETTA
Practice Address - State:GA
Practice Address - Zip Code:30064-3288
Practice Address - Country:US
Practice Address - Phone:770-424-0647
Practice Address - Fax:770-590-5990
Is Sole Proprietor?:No
Enumeration Date:2006-11-20
Last Update Date:2008-05-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GA16447207R00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207R00000XAllopathic & Osteopathic PhysiciansInternal Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
GA582142384OtherTRICARE
GA00193223FMedicaid
GA110092128OtherRAIL ROAD MEDICARE
GA1215001144OtherBLUE CROSS BLUE SHIELD
GA5986187OtherCIGNA
GA582142384OtherMAIL HANDLERS
GA124860510967OtherHUMANA
GA4231143OtherAETNA
GA124860510967OtherHUMANA
GA11BDHZXMedicare PIN