Provider Demographics
NPI:1275533176
Name:WHITE, JOHN C (MD)
Entity Type:Individual
Prefix:
First Name:JOHN
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 1:1615 MAPLE LANE
Mailing Address - Street 2:
Mailing Address - City:ASHLAND
Mailing Address - State:WI
Mailing Address - Zip Code:54806
Mailing Address - Country:US
Mailing Address - Phone:715-685-5513
Mailing Address - Fax:718-682-4022
Practice Address - Street 1:1615 MAPLE LANE
Practice Address - Street 2:
Practice Address - City:ASHLAND
Practice Address - State:WI
Practice Address - Zip Code:54806
Practice Address - Country:US
Practice Address - Phone:715-685-5513
Practice Address - Fax:718-682-4022
Is Sole Proprietor?:No
Enumeration Date:2005-07-21
Last Update Date:2020-11-24
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WI37688207P00000X
MEMD23757207P00000X
WI37688-20207Q00000X, 207P00000X
WI37688-020207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207P00000XAllopathic & Osteopathic PhysiciansEmergency Medicine
No207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
390908320OtherSTANDARD TAX ID NUMB
0124793OtherMEDICA PROVIDER NUMB
32252000OtherGROUP HEALTH OF EAU
P00341834OtherPALMETTO GBA RR ME
WI32252000Medicaid
314P8WHOtherBLUE CROSS BLUE SHIE
G28181OtherAMERICAS PPO
HP60964OtherHEALTH PARTNERS
1011768OtherPREFERRED ONE
P00341834OtherPALMETTO GBA RR ME
390908320OtherSTANDARD TAX ID NUMB
WI004200496Medicare ID - Type Unspecified