Provider Demographics
NPI:1407532187
Name:WHITE, DEMETRIUS
Entity Type:Individual
Prefix:MR
First Name:DEMETRIUS
Middle Name:
Last Name:WHITE
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:414 MCCLURE ST
Mailing Address - Street 2:
Mailing Address - City:LEHIGH ACRES
Mailing Address - State:FL
Mailing Address - Zip Code:33972-1046
Mailing Address - Country:US
Mailing Address - Phone:239-361-2090
Mailing Address - Fax:
Practice Address - Street 1:414 MCCLURE ST
Practice Address - Street 2:
Practice Address - City:LEHIGH ACRES
Practice Address - State:FL
Practice Address - Zip Code:33972-1046
Practice Address - Country:US
Practice Address - Phone:239-361-2090
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2023-06-26
Last Update Date:2023-06-26
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FL2301983172A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes172A00000XOther Service ProvidersDriver