Provider Demographics
NPI:1487650123
Name:WHITE, JOE MIKE (MD)
Entity Type:Individual
Prefix:
First Name:JOE
Middle Name:MIKE
Last Name:WHITE
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:J
Other - Middle Name:MIKE
Other - Last Name:WHITE
Other - Suffix:
Other - Last Name Type:Professional Name
Other - Credentials:MD
Mailing Address - Street 1:220 N RIDGEWAY DR
Mailing Address - Street 2:
Mailing Address - City:CLEBURNE
Mailing Address - State:TX
Mailing Address - Zip Code:76033-4115
Mailing Address - Country:US
Mailing Address - Phone:817-556-4800
Mailing Address - Fax:817-556-4825
Practice Address - Street 1:3517 SW WILSHIRE BLVD
Practice Address - Street 2:
Practice Address - City:JOSHUA
Practice Address - State:TX
Practice Address - Zip Code:76058-9659
Practice Address - Country:US
Practice Address - Phone:817-447-1151
Practice Address - Fax:817-529-8927
Is Sole Proprietor?:No
Enumeration Date:2005-06-27
Last Update Date:2018-01-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TXF6345207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
TX121078303Medicaid
TX882572Medicare ID - Type Unspecified
TX121078303Medicaid