Provider Demographics
NPI:1417083064
Name:WHITE, DEREK OMAR (PT)
Entity Type:Individual
Prefix:
First Name:DEREK
Middle Name:OMAR
Last Name:WHITE
Suffix:
Gender:M
Credentials:PT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:529 W 1200 N
Mailing Address - Street 2:
Mailing Address - City:OREM
Mailing Address - State:UT
Mailing Address - Zip Code:84057-2948
Mailing Address - Country:US
Mailing Address - Phone:801-226-5565
Mailing Address - Fax:801-226-5565
Practice Address - Street 1:50 E 9000 S
Practice Address - Street 2:
Practice Address - City:SANDY
Practice Address - State:UT
Practice Address - Zip Code:84070-2201
Practice Address - Country:US
Practice Address - Phone:801-561-9839
Practice Address - Fax:801-352-0027
Is Sole Proprietor?:No
Enumeration Date:2007-02-26
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
UT346435-2401225100000X
WAPT00010324225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist