Provider Demographics
NPI:1417715368
Name:WHITE, BILLY BLAKE III (RA (RADIOLOGIST ASS))
Entity Type:Individual
Prefix:MR
First Name:BILLY
Middle Name:BLAKE
Last Name:WHITE
Suffix:III
Gender:M
Credentials:RA (RADIOLOGIST ASS)
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
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Other - Credentials:
Mailing Address - Street 1:412 BAYOU RD
Mailing Address - Street 2:
Mailing Address - City:WINTER HAVEN
Mailing Address - State:FL
Mailing Address - Zip Code:33884-2507
Mailing Address - Country:US
Mailing Address - Phone:863-651-7255
Mailing Address - Fax:
Practice Address - Street 1:1305 LAKELAND HILLS BLVD
Practice Address - Street 2:
Practice Address - City:LAKELAND
Practice Address - State:FL
Practice Address - Zip Code:33805-4542
Practice Address - Country:US
Practice Address - Phone:863-688-2334
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2024-03-06
Last Update Date:2024-03-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLRA63243U00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes243U00000XTechnologists, Technicians & Other Technical Service ProvidersRadiology Practitioner Assistant