Provider Demographics
NPI:1427044098
Name:WHITE, MALCOLM A JR (MD)
Entity Type:Individual
Prefix:MR
First Name:MALCOLM
Middle Name:A
Last Name:WHITE
Suffix:JR
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 1:2120 E JOHNSON AVE
Mailing Address - Street 2:SUITE 103
Mailing Address - City:PENSACOLA
Mailing Address - State:FL
Mailing Address - Zip Code:32514-6036
Mailing Address - Country:US
Mailing Address - Phone:850-494-3965
Mailing Address - Fax:850-494-3966
Practice Address - Street 1:2120 E JOHNSON AVE
Practice Address - Street 2:SUITE 103
Practice Address - City:PENSACOLA
Practice Address - State:FL
Practice Address - Zip Code:32514-6036
Practice Address - Country:US
Practice Address - Phone:850-494-3965
Practice Address - Fax:850-494-3966
Is Sole Proprietor?:No
Enumeration Date:2005-09-20
Last Update Date:2013-11-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLME35996208000000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208000000XAllopathic & Osteopathic PhysiciansPediatrics
Provider Identifiers
StateIdentifier IDID TypeIssuer
FL065069200Medicaid
FL17470YMedicare ID - Type Unspecified
FL065069200Medicaid