Provider Demographics
NPI:1376640540
Name:WHITE, JASON T (DPM)
Entity Type:Individual
Prefix:
First Name:JASON
Middle Name:T
Last Name:WHITE
Suffix:
Gender:M
Credentials:DPM
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:15 S FOREST RD
Mailing Address - Street 2:
Mailing Address - City:WILLIAMSVILLE
Mailing Address - State:NY
Mailing Address - Zip Code:14221-6425
Mailing Address - Country:US
Mailing Address - Phone:716-634-5993
Mailing Address - Fax:716-478-0946
Practice Address - Street 1:15 S FOREST RD
Practice Address - Street 2:
Practice Address - City:WILLIAMSVILLE
Practice Address - State:NY
Practice Address - Zip Code:14221-6425
Practice Address - Country:US
Practice Address - Phone:716-634-5993
Practice Address - Fax:716-478-0946
Is Sole Proprietor?:Yes
Enumeration Date:2006-09-20
Last Update Date:2014-04-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NYN005864213E00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes213E00000XPodiatric Medicine & Surgery Service ProvidersPodiatrist
Provider Identifiers
StateIdentifier IDID TypeIssuer
00026080003OtherUNIVERA
000526926002OtherBLUE CROSS BLUE SHIELD WN
000526926001OtherBLUE CROSS BLUE SHIELD WN
NY02344012Medicaid
00026080003OtherUNIVERA
NYP00439984Medicare PIN
NY4825750001Medicare NSC
NYRB2379Medicare PIN