Provider Demographics
NPI:1407959422
Name:WHITE, KEITH ALLEN (MD)
Entity Type:Individual
Prefix:
First Name:KEITH
Middle Name:ALLEN
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:PO BOX 6149
Mailing Address - Street 2:
Mailing Address - City:ALOHA
Mailing Address - State:OR
Mailing Address - Zip Code:97007-0149
Mailing Address - Country:US
Mailing Address - Phone:503-352-8657
Mailing Address - Fax:503-352-8658
Practice Address - Street 1:1430 MONMOUTH ST
Practice Address - Street 2:
Practice Address - City:INDEPENDENCE
Practice Address - State:OR
Practice Address - Zip Code:97351
Practice Address - Country:US
Practice Address - Phone:503-838-1133
Practice Address - Fax:503-838-5138
Is Sole Proprietor?:No
Enumeration Date:2006-09-06
Last Update Date:2021-04-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
ORMD10976207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
OR26934-0Medicaid
OR26934-0Medicaid
C94063Medicare UPIN