Provider Demographics
NPI:1447428636
Name:WHITE, KEENON (MD)
Entity Type:Individual
Prefix:
First Name:KEENON
Middle Name:
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 1:9111 ANTIQUE ALY UNIT 1
Mailing Address - Street 2:
Mailing Address - City:BRIDGEVILLE
Mailing Address - State:DE
Mailing Address - Zip Code:19933-4682
Mailing Address - Country:US
Mailing Address - Phone:302-337-9320
Mailing Address - Fax:302-337-9640
Practice Address - Street 1:9111 ANTIQUE ALY UNIT 1
Practice Address - Street 2:
Practice Address - City:BRIDGEVILLE
Practice Address - State:DE
Practice Address - Zip Code:19933-4682
Practice Address - Country:US
Practice Address - Phone:302-337-9320
Practice Address - Fax:302-337-9640
Is Sole Proprietor?:No
Enumeration Date:2008-02-11
Last Update Date:2022-07-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NJ26NP05281400164W00000X
390200000X
DEC1-0012179207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
No164W00000XNursing Service ProvidersLicensed Practical Nurse
No390200000XStudent, Health CareStudent in an Organized Health Care Education/Training Program
Provider Identifiers
StateIdentifier IDID TypeIssuer
DE1447428636Medicaid