Provider Demographics
NPI:1538101647
Name:WHITE, TIQUETTE MASON (MD)
Entity Type:Individual
Prefix:
First Name:TIQUETTE
Middle Name:MASON
Last Name:WHITE
Suffix:
Gender:F
Credentials:MD
Other - Prefix:
Other - First Name:TIQETTE
Other - Middle Name:SHAUNTE
Other - Last Name:MASON
Other - Suffix:
Other - Last Name Type:Other Name
Other - Credentials:
Mailing Address - Street 1:868 YORK AVE SW
Mailing Address - Street 2:
Mailing Address - City:ATLANTA
Mailing Address - State:GA
Mailing Address - Zip Code:30310-2750
Mailing Address - Country:US
Mailing Address - Phone:404-752-1400
Mailing Address - Fax:404-758-0740
Practice Address - Street 1:868 YORK AVE SW
Practice Address - Street 2:
Practice Address - City:ATLANTA
Practice Address - State:GA
Practice Address - Zip Code:30310-2750
Practice Address - Country:US
Practice Address - Phone:404-752-1400
Practice Address - Fax:404-758-0740
Is Sole Proprietor?:No
Enumeration Date:2006-06-12
Last Update Date:2012-02-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GA055317208000000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208000000XAllopathic & Osteopathic PhysiciansPediatrics
Provider Identifiers
StateIdentifier IDID TypeIssuer
GA464267615Medicaid