Provider Demographics
NPI:1225034317
Name:WHITE, CHARLES C (MD)
Entity Type:Individual
Prefix:DR
First Name:CHARLES
Middle Name:C
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 1:40 CHURCH AVE
Mailing Address - Street 2:STE 201
Mailing Address - City:WAREHAM
Mailing Address - State:MA
Mailing Address - Zip Code:02571-2093
Mailing Address - Country:US
Mailing Address - Phone:508-295-3193
Mailing Address - Fax:508-295-4635
Practice Address - Street 1:40 CHURCH AVE
Practice Address - Street 2:STE 201
Practice Address - City:WAREHAM
Practice Address - State:MA
Practice Address - Zip Code:02571-2093
Practice Address - Country:US
Practice Address - Phone:508-295-3193
Practice Address - Fax:508-295-4635
Is Sole Proprietor?:Yes
Enumeration Date:2005-06-23
Last Update Date:2014-02-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MA53631174400000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes174400000XOther Service ProvidersSpecialist
Provider Identifiers
StateIdentifier IDID TypeIssuer
MA110071159AMedicaid
MAB74519Medicare UPIN