Provider Demographics
NPI:1366486805
Name:WHITE, CHARLES D (MD)
Entity Type:Individual
Prefix:DR
First Name:CHARLES
Middle Name:D
Last Name:WHITE
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:
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Mailing Address - Street 1:PO BOX 510004
Mailing Address - Street 2:
Mailing Address - City:SALT LAKE CITY
Mailing Address - State:UT
Mailing Address - Zip Code:84151-0004
Mailing Address - Country:US
Mailing Address - Phone:801-213-3900
Mailing Address - Fax:801-585-3655
Practice Address - Street 1:1138 E WILMINGTON AVE
Practice Address - Street 2:
Practice Address - City:SALT LAKE CITY
Practice Address - State:UT
Practice Address - Zip Code:84106-2819
Practice Address - Country:US
Practice Address - Phone:801-413-0250
Practice Address - Fax:801-463-0313
Is Sole Proprietor?:No
Enumeration Date:2006-06-15
Last Update Date:2021-12-17
Deactivation Date:
Deactivation Code:
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Provider Licenses
StateLicense IDTaxonomies
UT311210-1205207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
UTU000086425Medicare PIN
UT005738601Medicare PIN
UTP00167581Medicare PIN
UTDA3651Medicare PIN