Provider Demographics
NPI:1245205178
Name:WHITE, JOHN
Entity Type:Individual
Prefix:
First Name:JOHN
Middle Name:
Last Name:WHITE
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1521 N 10TH ST
Mailing Address - Street 2:
Mailing Address - City:BLYTHEVILLE
Mailing Address - State:AR
Mailing Address - Zip Code:72315-1424
Mailing Address - Country:US
Mailing Address - Phone:870-763-4224
Mailing Address - Fax:870-763-4325
Practice Address - Street 1:1521 N 10TH ST
Practice Address - Street 2:
Practice Address - City:BLYTHEVILLE
Practice Address - State:AR
Practice Address - Zip Code:72315-1424
Practice Address - Country:US
Practice Address - Phone:870-763-4224
Practice Address - Fax:870-763-4325
Is Sole Proprietor?:Not Answered
Enumeration Date:2006-02-22
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
ARE1142174400000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes174400000XOther Service ProvidersSpecialist
Provider Identifiers
StateIdentifier IDID TypeIssuer
ARA42691Medicare UPIN
AR5K303Medicare ID - Type Unspecified