Provider Demographics
NPI:1376575225
Name:WHITE, BENNIE R JR (MD)
Entity Type:Individual
Prefix:
First Name:BENNIE
Middle Name:R
Last Name:WHITE
Suffix:JR
Gender:M
Credentials:MD
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Mailing Address - Street 1:794 MCDONOUGH RD
Mailing Address - Street 2:SUITE 105
Mailing Address - City:JACKSON
Mailing Address - State:GA
Mailing Address - Zip Code:30233-1572
Mailing Address - Country:US
Mailing Address - Phone:770-775-2341
Mailing Address - Fax:770-775-3668
Practice Address - Street 1:794 MCDONOUGH RD
Practice Address - Street 2:SUITE 105
Practice Address - City:JACKSON
Practice Address - State:GA
Practice Address - Zip Code:30233-1572
Practice Address - Country:US
Practice Address - Phone:770-775-2341
Practice Address - Fax:770-775-3668
Is Sole Proprietor?:No
Enumeration Date:2006-07-07
Last Update Date:2012-12-18
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Provider Licenses
StateLicense IDTaxonomies
GA056245207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
GA345029068AMedicaid
GA08CBCKHMedicare PIN