Provider Demographics
NPI:1396816930
Name:WHITE, TY A (MD)
Entity Type:Individual
Prefix:DR
First Name:TY
Middle Name:A
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 1:3908 S PILLSBERRY AVE
Mailing Address - Street 2:
Mailing Address - City:SIOUX FALLS
Mailing Address - State:SD
Mailing Address - Zip Code:57103-7273
Mailing Address - Country:US
Mailing Address - Phone:605-331-0662
Mailing Address - Fax:605-335-3505
Practice Address - Street 1:1100 E 26TH ST
Practice Address - Street 2:
Practice Address - City:SIOUX FALLS
Practice Address - State:SD
Practice Address - Zip Code:57105-4023
Practice Address - Country:US
Practice Address - Phone:605-338-7098
Practice Address - Fax:605-335-3505
Is Sole Proprietor?:No
Enumeration Date:2006-11-13
Last Update Date:2009-09-01
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
SD5204207L00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207L00000XAllopathic & Osteopathic PhysiciansAnesthesiology
Provider Identifiers
StateIdentifier IDID TypeIssuer
IA567719Medicaid
MN150L5WHOtherBLUE CROSS MN
MN163453400Medicaid
SD4996133OtherBLUE CROSS SD
SD5701090Medicaid
NE46041879113Medicaid
NE46041879113Medicaid
P00125054Medicare PIN