Provider Demographics
NPI:1477559631
Name:WHITE, MARK WILLIAM (MD)
Entity Type:Individual
Prefix:
First Name:MARK
Middle Name:WILLIAM
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 1:11945 SAN JOSE BLVD
Mailing Address - Street 2:STE 300
Mailing Address - City:JACKSONVILLE
Mailing Address - State:FL
Mailing Address - Zip Code:32223-1627
Mailing Address - Country:US
Mailing Address - Phone:904-396-1725
Mailing Address - Fax:904-396-4893
Practice Address - Street 1:11945 SAN JOSE BLVD.
Practice Address - Street 2:BLDG 300
Practice Address - City:JACKSONVILLE
Practice Address - State:FL
Practice Address - Zip Code:32223-1627
Practice Address - Country:US
Practice Address - Phone:904-396-1725
Practice Address - Fax:904-399-1717
Is Sole Proprietor?:No
Enumeration Date:2005-06-22
Last Update Date:2020-09-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLME00754742086S0127X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2086S0127XAllopathic & Osteopathic PhysiciansSurgeryTrauma Surgery
Provider Identifiers
StateIdentifier IDID TypeIssuer
FL107281OtherFHCP
FLP01102622OtherRAILROAD MEDICARE
FLE5704XMedicare PIN
FL107281OtherFHCP